Perspectives in Biology and Medicine

REFUSING MEDICAL TREATMENT LYNN M. PETERSON* When a competent patient with a treatable illness refuses life-saving or life-prolonging medical therapy, a serious dilemma is created for the medical practitioner. Failure to treat hastens the patient's demise; treating against the patient's wishes denies free, autonomous choice and infringes on the person's fundamental right to decide what is to be done to his or her body. When treatment refusal occurs in the hospital setting, it arouses further tension by conflicting with the standards of practice and the goals of medicine. These conflicts are so troublesome that it may be necessary to have a court adjudicate between opposing views. Treatment refusal when survival is at stake raises important issues about the limits of the doctor's duty to the patient. Simply accepting the denial respects the patient's prerogative to choose and is consistent with values of individual freedom deeply embedded in our culture and society . But is this an appropriate response for a doctor who "cares" ? Can he or she be certain that this was "really" the patient's choice? Would the patient regard the choice as wrong if given further information or in possession of more experience? Would the patient come to a different conclusion if he or she truly appreciated the alternatives? The doctor who cares for and about the patient necessarily encounters such questions . To illuminate the issue, two patients who refused treatment are discussed . In one instance, the refusal was accepted; in the other, it was rejected. The circumstances, the reasons for the decisions, and the effect of their actions on those close to them differed significantly. Analyzing these examples suggests an approach to the problem of refusal, which treats patients with respect and at the same time avoids needless loss of life. ?Department of Social Medicine and Department of Surgery, Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115.© 1988 by The University of Chicago. All rights reserved. 003 1-5982/88/3 10 1-0593$0 1 .00 454 I Lynn M. Peterson · Refusing Medical Treatment Patients CASE 1 Mrs. A, a 65-year-old woman who developed rectal bleeding, was found to have a 5-cm villous adenoma in the rectum. She was otherwise in excellent health. Her tumor was within 2 cm of the dentate line making resection and rectal preservation impossible. Initial biopsies were benign, but the size of the lesion made it likely that a small focus of carcinoma existed elsewhere in the lesion. Chest X-ray, CEA, and abdominal exam were negative. Local, transrectal complete excision was performed; histologically, there was a small focus of superficially invasive carcinoma in the center of the adenoma. The invasion was confined to the lamina propria. Further therapy consisting of resection of the entire rectum and a permanent colostomy was advised, but she refused. Her husband of nearly 30 years had died 2 years previously of adenocarcinoma of the rectum. He had undergone an abdominoperineal resection in an attempt to cure him of the cancer. Unfortunately , he developed local recurrence, shortly after the operation, requiring radiotherapy. Shortíy thereafter, disseminated disease became evident, and he was given chemotherapy. Later inguinal lymph nodes became involved, and he was given further radiation that produced skin necrosis and ultimately hemorrhage from his femoral artery. During these 2 years, he suffered considerably and spent a great deal of time in the hospital, and none of the treatments met his expectations. Mrs. A, who was involved in his care, resolved that she would never go through such an experience. Her refusal was based on knowledge of her husband's treatment for a similar condition, the frustration she and her husband experienced when he failed to gain relief despite aggressive treatment, and the fear and anxiety created by the possibility that she might experience the same outcome. She sought further independent consultation from surgeons, psychiatrists, family, and friends. AU supported her decision to refuse aggressive, resectional therapy. Nine months later she developed a cough that lasted for 2 weeks. A chest X-ray to evaluate the cough suggested pulmonary metastases. Indeed , on physical exam she had an enlarged, nodular liver. A liver scan suggested metastases; a...