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Chapter 5
Preferences of Patients
Section 1: Competent refusal of treatment
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Persons who are well informed and have
decisional capacity sometimes refuse
recommended treatment.
Physicians may be confronted with an ethical
problem:
Does the physician’s responsibility to
help the patient ever override the patient’s
freedom?
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Refusal of care by a competent and informed
adult should be respected, even if that refusal
would lead to serious harm to the individual.
This is ethically supported by the principle of
autonomy.
Refusal on grounds of religious or cultural
belief
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Case Mr. G. comes to a physician for treatment of
peptic ulcer. He says he is a Jehovah’s Witness. He
is a firm believer and knows his disease is one that
eventually may require administration of blood. He
shows the physician a signed card affirming his
membership snad denying permission for blood
transfusion. He quotes the biblical passage on
which he bases his belief:
“I (Jehovah) said to the children of Israel, ‘No one
among you shall eat blood, nor shall any stranger
that dwells among you eat blood.”
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The physician inquires of her Episcopal
clergyman about the interpretation of this
passage. He reports that no Christian
denomination except the Jehovah’s
Witnesses takes this text to prohibit
transfusion. The physician considers that her
patient’s preferences impose on her an
inferior standard of care. She wonders
whether she should accept this patient under
her care.
Comment:
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As a general principle, the unusual beliefs
and choices of other persons should be
tolerated if they pose no threat to other
parties.
The patient’ s preferences should be
respected, even though they appear
mistaken to others.
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Is there any clinical evidence of patient’s
incapacity?
It forbids auto-transfusion. But it may allow
administration of blood fraction, such as
immune globulin, clotting factors, albumin,
and erythropoietin. It is advisable for the
physician to determine exactly the content
of a particular patient’s belief from the
patient and from church elders.
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Is this transfusion necessary?
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The validity or truth of a religious belief is
not relevant to the clinical decision. Instead,
the sincerity of those who hold it and their
ability to understand its consequences for
their lives are the relevant issues in this type
of case.
Recommendation:
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Mr. G’s refusal should be respected.
Irrational refusal of treatment
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Occasionally, refusal of care may appear
irrational, that is, contrary to the welfare of
the person making the decision without any
reasonable justification.
It is difficult to discern why a person should
refuse an obvious benefit or to know whether
they are really refusing.
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Case Mr. cure came to the ED with signs and
symptoms suggestive of bacterial meningitis.
When he was told his diagnosis and that he
would be admitted to the hospital for
treatment with antibiotics, he refused further
care, without giving a reason. He would not
engage in discussion with the staff about his
refusal.
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The physician explained the extreme dangers
of going untreated and the minimal risk of
treatment. The young man persisted in his
refusal and declined to discuss the matter
further. Other than this strange adamancy, he
exhibited no evidence of mental derangement
or altered mental status that would suggest
decisional incapacity.
Comment:
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The initial consent for diagnosis was implicit
in the young man’s allowing himself to be
brought to the ED. The patient’s refusal of
treatment, however, unexpected introduced
an incongruence between medical indications
and patient preferences.
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It might be argued that the physician should
simply permit the patient to refuse treatment
and suffer the consequence, because the
patient showed no objective signs of
incapacitation or serious psychiatric
impairment and because competent patients
have the right to make their own(sometimes
risky) decisions.
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However, when the risk of treatment is low
and the benefit is great, the risk of
nontreatment is high and the “benefits” of
nontreatment are small, it is ethically
obligatory for the physician to probe further to
determine why the patient inexplicably
refused treatment.
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This case poses a genuine ethical conflict
between the patient’s personal autonomy and
the paternalistic values that favor medical
intervention for the patient’s own good.
Recommendation:
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This is a genuine moral dilemma: The
principle of beneficence and the principle of
autonomy seem to dictate contradictory
courses of action. In medical care, dilemmas
cannot merely be contemplated; they must be
resolved. Thus, we resolve it in favor of
treatment against the expressed preferences
of the patient. In offering this counsel, we
favor paternalistic intervention at the expense
of personal autonomy.
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It is difficult to believe this young man wishes
to die. We accept as ethically permissible the
unauthorized treatment of an apparently
person.
The case illustrate that physician often are
pressured by circumstances to make
decisions before all relevant information is
known. Thus, the rightness or wrongness of
the clinical decision always must be
assessed with respect to the clinician’s
knowledge at the time of the decision.
refusal of information
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persons have a right to information about
themselves. Similarly, they have the right to
refuse information ot to ask the physician not
to inform them.
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Should the physician override the
patient’s stated preference not to know about
her condition?
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Should physicians withhold unpleasant
information about prognosis to protect the
patient from depression or other negative,
potential damaging emotions?
give patient general information;
avoids withholding too much too long or
disclosing too much too soon;
considering the patient’s capacity .
Advance planning
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The persons have the responsibility and the
right to make decisions about how they
should be treated during serious illness.
However, serious illness often deprives
patients of the abilities to make decisions in
their own behalf.
In recent years, the concept of “advance
planning” has been widely promoted as one
solution to this problem.
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Advance planning encourage individuals to
make known to physicians how they would
wish to be treated at a future time when they
might be unable to participate in decisions
about their care and to to inform the
physician about the person they most trust to
decide on their behalf.
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The most important features of advance
planning is discussion with one’s family and a
conference with one’s doctor.
The physician will document this
conversation in the patient’s record where it
will be available in time of crisis.
It has become more common in routine
medical care and is especially important in
terminal care.
The limits of patient preferences
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The preferences of patients have significant
moral authority and must be considered in
every treatment decision.
However, the authority of patients’
preferences is not unlimited.
The ethical obligation of physicians are
defined not only by the wishes of their patient
but also by the goals the medicine.
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Physicians have no obligation to perform
actions beyond or contradictory to the goals
of medicine, even when they requested to do
so by patients.
Thus, patents have no right to demand that
physicians provide medical care that is
contraindicated, such as necessary surgery,
or treatments.
World Medical Association International
Code of Medical Ethics
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DUTIES OF PHYSICIANS IN GENERAL
A PHYSICIAN SHALL always exercise
his/her independent professional judgment
and maintain the highest standards of
professional conduct.
A PHYSICIAN SHALL respect a competent
patient's right to accept or refuse treatment. A
PHYSICIAN SHALLnot allow his/her
judgment to be influenced by personal profit
or unfair discrimination.
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A PHYSICIAN SHALL be dedicated to providing
competent medical service in full professional and
moral independence, with compassion and respect
for human dignity.
A PHYSICIAN SHALL deal honestly with patients
and colleagues, and report to the appropriate
authorities those physicians who practice unethically
or incompetently or who engage in fraud or
deception.
A PHYSICIAN SHALL not receive any financial
benefits or other incentives solely for referring
patients or prescribing specific products.
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A PHYSICIAN SHALL respect the rights
and preferences of patients, colleagues, and
other health professionals.
A PHYSICIAN SHALL recognize his/her
important role in educating the public but
should use due caution in divulging
discoveries or new techniques or treatment
through non-professional channels.
A PHYSICIAN SHALL certify only that
which he/she has personally verified
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A PHYSICIAN SHALL strive to use health
care resources in the best way to benefit
patients and their community.
A PHYSICIAN SHALL seek appropriate care
and attention if he/she suffers from mental or
physical illness.
A PHYSICIAN SHALL respect the local and
national codes of ethics
DUTIES OF PHYSICIANS TO
PATIENTS
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A PHYSICIAN SHALLalways bear in mind the
obligation to respect human life.
A PHYSICIAN SHALLact in the patient's best
interest when providing medical care.
A PHYSICIAN SHALLowe his/her patients
complete loyalty and all the scientific
resources available to him/her. Whenever an
examination or treatment is beyond the
physician's capacity, he/she should consult
with or refer to another physician who has the
necessary ability.
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A PHYSICIAN SHALL respect a patient's
right to confidentiality. It is ethical to disclose
confidential information when the patient
consents to it or when there is a real and
imminent threat of harm to the patient or to
others and this threat can be only removed
by a breach of confidentiality.
A PHYSICIAN SHALL give emergency care
as a humanitarian duty unless he/she is
assured that others are willing and able to
give such care.
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A PHYSICIAN SHALL in situations when
he/she is acting for a third party, ensure that
the patient has full knowledge of that situation.
A PHYSICIAN SHALL not enter into a sexual
relationship with his/her current patient or into
any other abusive or exploitative relationship.
DUTIES OF PHYSICIANS TO
COLLEAGUES
A PHYSICIAN SHALL behave towards colleagues
as he/she would have them behave towards him/her.
A PHYSICIAN SHALLNOT undermine the patientphysician relationship of colleagues in order to
attract patients.
A PHYSICIAN SHALL when medically necessary,
communicate with colleagues who are involved in
the care of the same patient. This communication
should respect patient confidentiality and be
confined to necessary information.
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Adopted by the 3rd General Assembly of the
World Medical Association, London, England,
October 1949
and amended by the 22nd World Medical
Assembly Sydney, Australia, August 1968
and the 35th World Medical Assembly Venice,
Italy, October 1983
and the WMA General Assembly, Pilanesberg,
South Africa, October 2006