Clinicians striving to help patients achieve healthcare
goals often encounter the perplexing dichotomy of the patient’s stated goals
and preferences and actions to the contrary. Some of these challenges can be
overcome with education and close follow up to help reinforce adherence to
medical recommendations, but other times, these barriers are more enigmatic.
Take for example, a patient who requires hemodialysis to
sustain life. She sometimes shows up for her outpatient dialysis, but more
often does not show up and is admitted to the hospital for emergent dialysis
several months in a row. In consultation with her providers she is adamant that
she does not want to die, and knows that she needs the dialysis to remain
alive. She is discharged, and the pattern continues. Liberal scheduling with
the outpatient service, transportation, reminders are all offered.
Psychological tests and support are provided, and yet, her action pattern of
not adhering to the treatment plan continues. Again, she is advised it is acceptable
to halt and she will be offered palliative care. She refuses, and says she
wants to live and will sit for dialysis. What is her genuine preference? Should
we honor these statements, or accept her actions as the more authentic
expression of her wishes? Though this hypothetical example is quite familiar to
renal care providers, the dynamic spans many scenarios leaving many
practitioners with a dilemma about the practical limits of honoring verbalized
wishes that are not supported by congruent actions.
In such scenarios, it seems that the principle of
beneficence overrides the obligation to interpret which autonomous expressions,
words or actions are most genuine. Though taxing, the duty to strive for a
restoration of well-being and recovery remain a central goal in contemporary
healthcare. I would suggest that a patient with discordant statements and
actions may have impaired ability to act as an autonomous agent, and for this
reason we must do our best to adhere to a plan of care that can be practically
The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.