Posted on October 8, 2019 at 9:37 AM
Adult patients are
presumed to have decisional capacity and have a right to refuse medical
treatment, not only from an ethical perspective but also a legal one. Patients with capacity have the right of
bodily integrity and personal autonomy, and the right to not be touched without
consent. The situation becomes more
problematic when adult patients, whom have been determined to lack decisional
capacity, actively object to recommended medical treatment or intervention
believed to be in their best interest. For this patient population treatment
over objection becomes a challenging ethical and legal issue that should not be
taken lightly by healthcare providers.
These patients, who may have the ability to not only verbally express
strong preferences against treatment, may also physically resist any bodily
intrusions. In most cases the required
effort to force treatment, using sedation or restraints, becomes ethically
problematic. At the same time, in cases
where it seems apparent that the patient will benefit from the recommended
medical treatment, allowing patients without capacity to not receive this
treatment is ethically troublesome.
There is no universal answer to situations in which patients
without capacity refuse treatment. The
question is: Should we employ a case
specific approach that carefully considers the following factors: the patient’s reason for refusal
(preferences), harms/risks/consequences without the recommended treatment, the
likelihood of the proposed treatment doing good, associated risks of the
proposed treatment, and the likely emotional effect of forced treatment on the
One of the most ethically complex decisions in medicine is
in deciding when to override the autonomy and/or preferences of a patient
deemed to lack decisional capacity and treat over the patient’s objection. This challenge exists even in the presence of
a healthcare agent or surrogate decision-maker.
The ethical justification for overriding a patient’s refusal of medical
treatment relies on the assessment of decisional capacity and even if
determined to lack capacity, patients may have capacity for some decisions but
not for more complex decisions. Capacity
is fluid and can fluctuate over time, particularly with conditions in which
cognitive impairment is present. There
are clinical situations in which beneficence outweighs autonomy and in which
the use of a soft paternalistic intervention is ethically justifiable whenever
it may effectively lead to a greater well-being. A soft paternalistic intervention serves to
protect patients from decisions that may significantly and needlessly alter
their life. In a situation in which the
autonomy and/or preferences of a patient are considered to be most important,
the use of a paternalistic intervention would not be justified, regardless of
the patient’s well-being.
Allowing a patient to suffer preventable harm that can
almost certainly be averted with medical intervention seems to be contrary to
the ethical principle of beneficence.
The challenge is in identifying and balancing the risk vs. benefit.
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