Recommendation for life support from 22 weeks. Kristina Bessolova/Shutterstock Dominic Wilkinson, University of Oxford When new guidance relating to the outcome and medical care of babies born extremely prematurely was recently released, it led some to call for UK abortion law to be revised. This was because one of the new recommendations from the British […]

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 patient?

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.       

Professor Dominic Wilkinson, Professor of Medical Ethics, University of Oxford. Consultant Neonatologist   This morning, the High Court judgement around medical treatment for five-year old Tafida Raqeeb was published. Tafida sustained severe brain damage from bleeding in the brain eight months ago. Her parents wish to take her to a hospital in Italy to continue […]

Professor Dominic Wilkinson, Professor of Medical Ethics, University of Oxford. Consultant Neonatologist   This morning, the High Court judgement around medical treatment for five-year old Tafida Raqeeb was published. Tafida sustained severe brain damage from bleeding in the brain eight months ago. Her parents wish to take her to a hospital in Italy to continue […]

By Charles Foster Informed consent, in practice, is a bad joke. It’s a notion created by lawyers, and like many such notions it bears little relationship to the concerns that real humans have when they’re left to themselves, but it creates many artificial, lucrative, and expensive concerns. Of course there are a few clinical situations […]

Written by Rebecca Brown, Stephanie Tierney, Amadea Turk. This post was originally published on the NIHR School for Primary Care Research website which can be accessed here.  Health problems often co-occur with social and personal factors (e.g. isolation, debt, insecure housing, unemployment, relationship breakdown and bereavement). Such factors can be particularly important in the context of non-communicable […]

by Professor Dominic Wilkinson, consultant neonatologist, Professor of Medical Ethics, University of Oxford.     In September, the high court will hear a legal challenge relating to the medical care of five-year old Tafida Raqeeb. She has been in intensive care since suffering a severe stroke in February this year. The doctors apparently believe that […]

by Leah McClimans, Ph.D.

The Autism CARES (Collaboration, Accountability, Research, Education and Support) Act is currently up for reauthorization before Congress.…

by Craig Klugman, Ph.D.

Steven Stryker was 75 years old when he died on May 13 at St. Joseph’s Hospital in Tampa.…

In a recent blog post on this site Dom Wilkinson, writing about the case of Vincent Lambert, said this: ‘If, as is claimed by Vincent’s wife, Vincent would not have wished to remain alive, then the wishes of his parents, of other doctors or of the Pope, are irrelevant. My views or your views on the […]