Should a doctor be able to allow a patient to refuse treatment for a life-threatening condition?

An increasingly common dilemma in the medical field has arisen — a patient refuses to be treated even though they are facing a life-threatening condition. What should the physician do? Should the patient be allowed to refuse life-saving treatment? Is it within the long-term best interests of the patient that the physician forcibly treats the patient? Several aspects need to be considered before the decision is made, the key ones being — ethics and morality, the mental capacity of the patient, conflicting religious or personal beliefs, and finance — that the patient may face.

Surprisingly, there is no fixed protocol for these onerous situations and the most common occurrence is the decision-making by a board of ethicists and medical practitioners. In the odd yet ever-occurring instance that a patient needs to be treated urgently but is refusing to undergo treatment, multiple aspects need to be discerned for the physician to make a unilateral decision.

Decision-Making Capacity (DMC)

Before we dive into the ethics of treating patients against their will, we must assess the patients’ state of mind. The ethics of the decision is often a secondary step to the patient’s mental situation. Patients can only make a potentially significant decision if they are ‘fit in mind’ to make such a life-changing decision. This responsible state of mind is often known as having Decision Making Capacity (DMC), and a patient can only be classified under this if they are not under the influence or intoxicated by alcohol, drugs, or have an altered mental status due to brain injury, psychiatric illness, schizophrenia, bipolar disorder, dementia, or other patho-psychological conditions. On the contrary, if the patient is suffering from one of these conditions, it is likely is that the physician will carry out the necessary life-saving treatment with the approval of the board of ethicists and physicians, even if it is against the will of the patient.

The concurring practice of Patient Autonomy or Bio-ethics establishes a patient’s right to determine what happens to their own body. A physician would need to respect a patient’s autonomy by acknowledging that patients who have Decision Making Capacity have the right to make decisions regarding their medical care, even if it contradicts the physicians’ recommendations.

Ethics and Morality

Considerations of ethics and morality can arise often. As a key priority, the patient should have the right to decide whether they undergo critical treatment as it may go against the will and ethics of the patient. In the case of life-long, intensive and painful post-operative treatment bears down against the patient’s will and desire to live long, thereby influencing the patient’s decision to end his ongoing pain. Such instances are at the core of the issue of ethics.

Life decisions may also be influenced by instances wherein the treatment conflicts with religious or personal beliefs of the patient. An example of this would be the Amish people, who do not believe in heart transplants. Christian Scientists have been known to believe in the absolute power of prayer to God, thereby refusing necessary life-saving treatment.

Ethics and moral considerations also emerge when there is a lack of finance for the treatment, either due to the inability of the patient or his family to afford the treatment or lack of medical insurance coverage. Expectedly, such occurrences are common in third world countries with accident injuries of the under-privileged and poor go untreated, and even unattended solely due to unaffordability of the treatment.

Shortage of life-saving medical equipment and supplies warranting the choice of one kind of patient over others present another dimension of the ethical and moral dilemma. To highlight a current occurring in several countries in these COVID-times, the lack of life-saving respirators has compelled doctors to prioritise younger patients to the elderly for life-saving treatments. Such is also the case in war-torn regions suffering limited medical supplies where doctors have to make split-second decisions to save some injured over others. Such widely occurring situations leave the question of ethics and morality painfully open and unanswered.

Legal Angle

The legal angel is well exemplified by a case in the American context. The 1991 Federal Patient Self Determination Act (PSDA) states that Americans would be able to refuse life-saving treatment if they had an optimal Decision-Making Capacity (DMC) in the situation of a critical life and death decision. In this background, a firefighter who had suffered severe full-thickness burns on much of his body, significant smoke inhalation, as well as a broken leg, was taken to the regional burns-centre. The concerned physician estimated the man’s chances of survival at a marginal 10% given a recent demise of a patient having suffered similar conditions. The firefighter, aware of his bleak chances, conveyed to the physician his decision not to undertake treatment in view of not only the long-lasting painful treatment but also remaining disfigured and disabled subsequently. He did not see any positive outcome for his treatment even if successful. The fire-fighter was in his full DMC and was permitted to exercise his right to revoke treatment under the PSDA Act.

Such situations relate closely with the practice of euthanasia, wherein an intensely suffering patient is permitted the right to choose to die by medical aid, given the painful and pathetic quality of life ahead. While such legal perspective remains debated, therefore, not made a law in most countries. Yet the right to die in extreme medical conditions has been made legal in few places such as Switzerland, Netherlands, Belgium, Canada, Australia, France, New Zealand, and the US.

Long-Term Life Perspective

With multiple considerations and practices giving patients in critical medical conditions the right to choose between life and death, the argument remains whether such decisions are taken by patients usually in a situation of extreme trauma and suffering would have been different given the longer-term perspective of life. What if a patient chooses to give up when chances are he recovers in the longer-term to live a fuller life? Medical history is replete with cases of miraculous long-term recovery of patients having suffered unimaginable trauma or suffering.

Conclusion

Our journey through the realms of morality, mental capacity, legality, and autonomy leads us to a rational and balanced perspective. The paramount life-and-death decision should ultimately lie in the hands of patients themselves. In critical medical situations, while the patient’s family, friends, and medical supervisors have valid and legitimate inputs and influences, the last word should always be that of the soul in question.

Patients in reasonable mental capacity should, undisputedly, be given the right to refuse treatment for a life-threatening condition in the background of all relevant information and consequences. It’s the ultimate form of respect and choice that should be given to a human in such critical life-death conditions. Let’s respect that!

‘To save a man’s life against his will is the same as killing him’

-Horace