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Patient autonomy is the ethical principle which represents that a patient who has the capacity to understand their medical condition and the risks and benefits of some action upon them, has the ethical right, under most circumstances, to make that decision for themselves and expect the physician to abide with their request.


But that is “under most circumstances”. I want to present two scenarios where a patient has stated “stop! I don’t want…” The question I pose to my visitors is whether a physician can ignore that request in each of the scenarios and if so why or why not should the patient’s request be followed or not followed. When do standards of medical practice trump a patient’s request? Standards of medical or surgical practice are specific behaviors, based on scientific literature but also based on the consensus of physicians about certain diagnostic or therapeutic actions and also on common behaviors or actions of doctors where they practice and which the profession of medicine place upon physicians as the physicians carries out their care of their patients. In this regard, if there is a difference between the two cases, what is the difference? ..Maurice.


Scenario 1:
Brain surgery of lesions is often performed on conscious patients to establish safe dissection around motor and sensory areas. A patient with skull opened and brain exposed demanded the surgeon to stop the operation at once despite understanding the consequences of fully terminating the surgery at this point and leaving the skull open. Instead of stopping, the surgeon had the patient anesthetized to allow proper closure of the skull thus was violating the patient's demand. Is what the surgeon did ethical?


Scenario 2:
An adult Jehovah’s Witness patient because of acute massive bleeding which cannot be rapidly stopped requires life saving blood transfusion but is awake and refuses blood transfusions based on the patient’s religion. The patient is informed that with the transfusion, the patient will live and the underlying bleeding problem can be resolved with no long term medical consequences. Without the transfusion, the patient could most likely die. The patient still refuses but the physician, as the patient is beginning to lose consciousness, violates the patient’s autonomous demand and begins the blood transfusions. Is what the physician did ethical?

Note: This topic was posted on my Bioethics Discussion Blog today.

http://bioethicsdiscussion.blogspot.com/2009/11/violation-of-patients-autonomy-is-that.html#comments

In scenario 1, the physician did the right thing. Common sense must be applied in this situation. You cannot just leave the patient's head "open" to infection...etc.

In scenario 2, The physician acted unethically. Unlike scenario 1, the physician took it upon him/herself to begin a procedure against the wishes of an adult presumably rational patient. The physician should face sanctions.

In scenario 1, the physician acted ethically. Due to the nature of the procedure the patient may not been competent to make his own healthcare decisions. This is especially true in this situation in which the patient does not seem to understand the implications of his decision.

However, in scenario 2, the physician did not make the right decision. The patient was informed about the medical situation and understood the consequences of not receiving a blood transfusion. In this situation the patient's right to refuse treatment should have been honored.

In my Clinical Ethics class, we recently studied the complex issue of giving blood products to Jehovah's Witness patients.

Here's one link that details JW blood product policy:

http://www.ajwrb.org/

In the 1st case the physician must close the lesion. It should have been explained to the patient before hand that once the procedure was started it could not be stopped without covering the surgical defect

In the second case the treatment should not have been given if a blood product had to be introduced. Being an oncologist , I've had similar situtations that required me to keep 'hands off 'therapy in spite of the fact that treatment  would have either saved the man's life or at least extended it.He died the next day.

Mike Derechin,MD <chinchin38@gmail.com>

Mike, in your appropriate "hands off therapy", would you, after explaining your basis for advising the treatment, challenge the patient to repeat back to you what the patient understood you had said and then challenge the patient to provide you with an explantion of the reason for the patient's rejection of therapy? Would you do all that or would you simply just accept the patient's rejection of your advice and keep "hands off"? If you did request that the patient explain to you the reason for rejection, how would you evaluate the response?  If you found the patient was unable to express a reason or the patient's reasoning conflicted with your own reasoning for your therapy, what would you do next? Still "Hands off"? or what? ..Maurice.

Respect for autonomy embodies the principle of the patient's negative right of refusal. It does not give the patient unlimited access to each and every whim nor does it commit a physician to doing an obvious wrong. The posed scenarios raise several questions:

1) Can the patient actually refuse to have his wound closed?

2) Do each of the patients continue to have decisional capacity?

3) What other governing principles are relevant?

Assuming both patients are decisional, a good case can be made that basic care (in fact the fundamental requirement for beneficence) would require that the surgeon close properly. However and equally good case can be made that the bone flap simply be properly preserved and stored and skin closed expeditiously. Either action comports with good care.

The second case seems a bit more staightforward. Jehovah's Witnesses live this. It's clear to each of them as they profess their faith. A decisional patient is entitled to refuse lifesaving therapy- this is no less true for a Jehovah's Witness. A decisional patient may refuse for any reason or no reason at all. 

John, I might challenge your last statement that "a decisional patient may refuse for any reason or no reason at all."  One of the tools a doctor must use to determine  whether the patient has decisional capacity is the patient's explanation of the decision which the patient has made.  "Any reason" is not good enough. There needs to be a reason presented by the patient which is reasonable and rational considering the information presented to the patient and the patient having already demonstrated understanding. The reason need not follow the doctor's view of what would be his or her own personal explanation of the decision under the circumstances. But it has to make sense in order to support the conclusion that the patient clearly understands the situation and thus has the capacity to make medical decisions in the first place. If no reason at all is offered, again evaluation of capacity may be impossible. 

To describe the process more fully, the determining of capacity is for the doctor to present to the patient information necessary to make a decision. Then to ask the patient to speak back what the patient had heard and what the patient understands. The patient should then be questioned if there any issues for which the patient needs more details and the doctor should then respond. The next step would be to have the patient present his or her decision. Finally, the patient must be asked, regardless of the decision or whether acceptable to the physician, to explain the decision. If all the previous observations suggested capacity but, as an example, in answer to the last question the patient replied "because the little men from Mars who have been talking to me told me how to decide" with a straight and ernest face, capacity should be questioned. ..Maurice.

Agreed. But if capacity is in question then the patient is, by definition, not decisional. Decisional patients may refuse for any reason or no reason at all. Whether the patient chooses to share the reason, or the physician believes it valid, is largely irrelevant. 

Avoiding a charge of battery once a decisional patient refuses or declines requires a judicial order or appointment of a guardian ad litem. No means no. The physician doesn't have to agree. 

John, I agree. What I wanted to emphasize was that having the patient explain a decision was one tool in determining capacity.  Regarding a patient who gives a unique explanation (from the doctor's point of view) as long as the explanation shows intelligible  use of the facts presented to the patient that is all that is necessary to establish that the patient has capacity to make his or her own decisions.  For example, a patient who explains the refusal of surgery based on finances but understanding the risk of no surgery and can repeat to the doctor regarding the clinical need for surgery should be considered to have capaicty. ..Maurice.

Rutul, I am trying to understand your analogy since I am not an engineer nor do I have a cryogenic engine nor the fuel nearby to activate its function even if I did have an empty potential cryogenic engine.  Any help with my ignorance? ..Maurice.