In lieu of an abstract, here is a brief excerpt of the content:Refusals of Treatment and Requests for DeathTom L. Beauchamp (bio)It would be hard to overestimate the importance of two decisions on physician-assisted suicide delivered recently by the Ninth and Second Circuit Courts (Compassion in Dying v. State of Washington, 79 F.3d 790 (9th Cir. 1996) (en banc), aff’g 850 F.Supp. 1454 (W.D. Wash. 1994), rev’g 49 F.3d 586 (9th Cir. 1995); Quill v. Vacco, 80 F.3d 716 (2nd (...) Cir. 1996). They are the highest courts yet to render an opinion on this subject, and their decisions have set the stage for the U.S. Supreme Court to take one of two paths: It will either say that (1) all citizens have a liberty interest in physician-assisted suicide, or that (2) each state may set its own policy on such matters. Whichever path is elected, a right to request physician-assisted suicide is a virtual certainty, at least in some states.These opinions are later segments of an evolving legal history in which courts have held that no criminal liability exists for withholding or withdrawing a life-sustaining treatment when physicians are directed to do so by a patient or an authorized surrogate (see Alan Meisel 1992). The decriminalization of suicide and the right to refuse a life-sustaining treatment now appear to be evolving into a rule that a patient has a legal right to control his or her death, or at least to obtain a lethal prescription. We are at a delicate point in this evolving history. Neither in law nor in bioethics is the justification of physician assistance in suicide the received opinion at the present time, but support for physician assistance in dying could soon become the received opinion in both disciplines.The leading edge of the wedge producing these changes has been widespread acceptance of an extensive right to refuse treatment. This right is today axiomatic in even conservative quarters of bioethics, but 20 years ago it was far from axiomatic that all patients have a right to refuse treatment. Few at that time judged that it would be both immoral and illegal for a physician not to forgo treatment in the face of a competent, authoritative refusal of any form of medical service or treatment.The justification for assistance in bringing about death in medicine is an extension of the justification for letting patients die. Letting a patient die by accepting a valid refusal to continue in life is directly analogous to helping a patient die by accepting a valid request for help. The high value we place on [End Page 371] rights of autonomy thereby spills over from the right to refuse to the underexplored right to request active assistance. 1 As the autonomy interest in this choice increases, denial of help to the patient becomes more burdensome.Those who defend the view that euthanasia and physician-assisted suicide are morally prohibited typically assume that assistance involves an act of killing, that acts of killing are impermissible, and that a defensible distinction exists between killing and letting die. However, this distinction has proved difficult to explicate, and the category of killing often seems distant from the problem at hand. For example, it is an eccentric view that a physician who prescribes a lethal medication to a patient thereby kills the patient (or, for that matter, lets the patient die) when the patient voluntarily ingests the medication and dies. So poor are the conceptual understandings of “killing” and “letting die” that conceptual confusion abounds as to which term to use in almost all morally difficult and controversial cases.A common view is that “letting die” is a matter of “ceasing useless treatments” after which patients die (Gaylin, Kass, Pellegrino, and Siegler 1988). This account is attractive, but too narrow. “Letting die” occurs in medicine under at least two circumstances: cessation of treatment because it is useless and cessation of treatment because it has been refused (which can occur even with useful treatments). Neither conceptually nor morally is “ceasing useless treatment” the proper way to state the condition under which many “letting-die” cases occur. It follows that the type of action—killing or letting... (shrink)

This article explores refusal of medical treatment by adult patients from ethical and legal perspectives. Initially, consequentialist and deontological ethical theory are outlined. The concepts of autonomy, paternalism and competence are described and an overview of Beauchamp and Childress’s principle-based approach to moral reasoning is given. Relevant common law is discussed and the provisions of the Mental Capacity Act 2005 in assessing competence is evaluated. In order to demonstrate the consideration of moral issues in clinical practice, ethical theory (...) is applied to two well-known incidents: the case of Re MB, where doubt over decision-making capacity led to a paternalistic act to override a patient’s choice; and the death of Emma Gough, a situation where respect for autonomy prevailed when healthcare staff acted lawfully in following a patient’s refusal of life-saving treatment. Finally, guidance from regulatory bodies on the roles and responsibilities of health professionals in relation to this topic are considered. (shrink)

Adolescents are routinely treated differently to adults, even when they possess similar capacities. In this article, we explore the justification for one case of differential treatment of adolescents. We attempt to make philosophical sense of the concurrent consents doctrine in law: adolescents found to have decision-making capacity have the power to consent to—and thereby, all else being equal, permit—their own medical treatment, but they lack the power always to refuse treatment and so render it impermissible. Other parties, (...) that is, individuals who exercise parental responsibility or a court, retain the authority to consent on an adolescent’s behalf. We explore four defences of the doctrine. We reject two attempts to defend the asymmetry in the power to consent to and refuse medical treatment by reference to transitional paternalism. We then consider and reject a stage of life justification. Finally, we articulate a justification based on the distinctiveness of adolescent well-being. (shrink)

Consensual homicide remains a crime in jurisdictions where active voluntary euthanasia has been legalized. At the same time, both jurisdictions, in which euthanasia is legal and those in which it is not, recognize that all patients (whether severely ill or not) have the right to refuse or withdraw medical treatment (including life-saving treatment). In this paper, I focus on the tensions between these three norms (the permission of active euthanasia, the permission to reject life-saving treatment, and the (...) prohibition of consensual homicide), assuming a justification of euthanasia based on the right to (personal) autonomy. I argue that the best way to provide a coherent account of these norms is to claim that patients have two distinct rights: the right to autonomy and the right to bodily integrity. This solution has some relevant implications for the discussion of the legalization of active euthanasia. (shrink)

Christian Scientists' refusal of medical care for their children illustrates the kind of conflict over moral and practical authority that can arise between groups in a pluralistic society. While consensus may not be possible, changes in the way both groups socialize members may allow the medical and Christian Science communities to achieve a compromise that is respectful to both.

In their recent article, Erbay et al considered whether a seriously injured patient should be able to refuse treatment if the refusal was based on a (mis)interpretation of religious doctrine. They argued that in such a case ‘what is important…is whether the teaching or philosophy used as a reference point has been in fact correctly perceived’ (p 653). If it has not been, they asserted that this eroded the patient's capacity to make an autonomous decision and that therefore, (...) in such cases, it is the role of the healthcare professional (HCP) to ‘assist patients to think more clearly and rationally’ (p 653). There are, however, a number of problems with the reasons why Erbay et al suggest we should help patients to rationalise their decisions and how HCPs should go about this. In this article, the author explores some of their main arguments regarding consent and rationality (particularly in relation to religious beliefs), as well as Erbay et al's normative claim that HCPs have an obligation to promote autonomy by helping patients to come to a ‘rational’ decision. Ultimately, the author agrees that the (temporary) solution to the dilemma presented in this scenario (which was to insert an intravenous cannula into the patient in order to allow an infusion of fluids in the event that he changed his mind) seemed both pragmatic and ethically permissible. However, it is suggested that the arguments which underpin this conclusion in Erbay et al's article are largely unsound. (shrink)

The vignette described in the introduction of this symposium raises a number of ethical and legal problems for physicians who work for correctional institutions and death row inmates. They are not confined to correctional physicians, however, as states have requested aid from practicing physicians in the community, and even from other states, when conflicts have arisen in the treatment of death row inmates as they near the date of execution. As outlined, the case involves a 48-year-old man with a (...) long history of schizophrenia, initially diagnosed at age 19. Compliant with medication, he remained generally free from positive symptoms-delusions and hallucinations. Nonetheless, he committed two murders during a robbery and was sentenced to death. Since his incarceration, the defendant has consistently refused psychotropic medications and has been forcibly medicated on several occasions when he exhibited violent outbursts and was overtly psychotic. (shrink)

The role of physicians in death penalty cases has provoked discussion in both the legal system as well as in professional organizations. Professional groups have responded by developing ethical guidelines advising physicians as to current ethical standards. Psychiatric dilemmas as a subspecialty with unique roles have required more specific guidelines. A clinical vignette provides a focus to explicate the conflicts.

In this essay, I will use a minimalist standard of decision-making capacity (DMC) to ascertain two cases in the medical ethics literature: the 1978 case of Mary C. Northern and a more recent case involving a paranoid war veteran (call him Jack). In both cases the patients refuse medical treatment out of denial that they are genuinely ill. I believe these cases illustrate two matters: (1) the need of holding oneself to a minimal DMC standard so as to make (...) as salient as possible the patient's own reasons for sometimes unusual treatment denials; (2) the need for clinicians and other relevant parties to exercise great sensitivity toward engaging, on the patient's own terms, idiosyncratic treatment refusals through regard for what I will call the patient’s conditional preferences. These are particularly relevant matters when a patient’s DMC is questionable yet he/she registers what may well be his/her settled preferences. (shrink)

Douglas T. Going above and beneath the call ….

The patient we call Danny was a mildly mentally retarded male in his mid-thirties who adamantly refused kidney dialysis when it was offered as the only therapeutic option for his progressive kidney failure. It was uncertain how fully Danny understood the implications of his refusal. To complicate the case still further, several “advocates” emerged to speak on Danny's behalf — each with a somewhat different interpretation of the situation and different sets of value presuppositions and ethical principles to apply (...) to the choice. We chronicle the development of this situation through a series of scenes; and in each scene we also attempt to clarify the ethical and medico-legal issues involved at that point. Danny was finally permitted to make this decision for himself — though more by default than by an agreement by all parties to honor his autonomy. Our hope is that this presentation will lead to further discussion and clarification of these important issues. (shrink)

This article is a critical analysis of Judge J. Skelly Wright's “Application of President and Directors of Georgetown College.” Wright's paper concerns the refusal of a Mrs. Jones to allow a blood transfusion needed to save her life and Wright's decision, based on a number of social, medical, legal, religious, and psychological facts, to permit the transfusion. The presentation is a close paraphrase of Wright's own case write-up. Critical expositions of five arguments explicitly advanced by Wright for his decision (...) to allow a transfusion are given, as are attempts to track down other justifying reasons he may have had for his decision. (shrink)

This article is a critical analysis of Judge J. Skelly Wright's “Application of President and Directors of Georgetown College.” Wright's paper concerns the refusal of a Mrs. Jones to allow a blood transfusion needed to save her life and Wright's decision, based on a number of social, medical, legal, religious, and psychological facts, to permit the transfusion. The presentation is a close paraphrase of Wright's own case write-up. Critical expositions of five arguments explicitly advanced by Wright for his decision (...) to allow a transfusion are given, as are attempts to track down other justifying reasons he may have had for his decision. (shrink)

The patient we call Danny was a mildly mentally retarded male in his mid-thirties who adamantly refused kidney dialysis when it was offered as the only therapeutic option for his progressive kidney failure. It was uncertain how fully Danny understood the implications of his refusal. To complicate the case still further, several “advocates” emerged to speak on Danny's behalf — each with a somewhat different interpretation of the situation and different sets of value presuppositions and ethical principles to apply (...) to the choice. We chronicle the development of this situation through a series of scenes; and in each scene we also attempt to clarify the ethical and medico-legal issues involved at that point. Danny was finally permitted to make this decision for himself — though more by default than by an agreement by all parties to honor his autonomy. Our hope is that this presentation will lead to further discussion and clarification of these important issues. (shrink)

Introduction:Prehospital emergency medicine is a specific field of emergency medicine. The basic approach of prehospital emergency medicine is to provide patients with medical intervention at the scene of the incident. This special environment causes health professionals to encounter various problems. One of the most important problems in this field is ethics, in particular questions involving refusal of treatment and the processes associated with it.Objective:The objective of this study is to identify emergency health professionals’ views regarding refusal of (...) treatment.Methods:This study was conducted with 356 health professionals who were on active duty in prehospital emergency health services. The data were collected through a form which included 10 statements. The participants were asked to indicate their level of agreement with the statements given by rating them between 0 and 10.Ethical considerations:Before conducting the research, permission was received from the local ethics committee. Participants were given written information about the purpose of the study. Participants were assured that their participation was voluntary.Results:The healthcare professionals with fewer years of experience in the profession and female participants adopted an attitude of giving priority to providing care. Young participants, in general, respected patient autonomy. However, paradoxically, when it comes to emergency medical cases, they expressed an opinion closer to paternalism.Conclusions:This study has found that prehospital emergency health professionals generally respect the patient’s right to refuse treatment; however, they do not prioritize this right when there is a life-threatening situation or when the person does not have decision-making capacity. In these cases, prehospital emergency health professionals tended to adopt a more paternalistic approach. (shrink)

In the present super-aging society, issues concerning what treatment should be given for incapacitated patients have become more important than ever before. This paper discusses whether or not an incapacitated patient’s refusal of treatment should be respected. The authors present a complete hypothetical scenario involving a 75-year-old moderately demented man suffering from malignant lymphoma. Of primary importance are the respect for patient dignity and the protection of human rights. Acts such as coercion, disregard, restriction, and surveillance can (...) be unethical in many situations. The effectiveness of chemotherapy for malignant lymphoma and its adverse outcomes could offset each other, leaving no net benefits for the patient. The patient is vulnerable and this very vulnerability requires the utmost protection and care. However, protection must be sensitive and comprehensive and the protection of his life at the expense of many other valuable factors is not justifiable. Coercing unwanted treatment would be intrusion, not protection, because of the physical and psychological suffering. When the refusal is explicit, consistent, and stable enough, it should to be viewed as true and current desire. Due to moderate dementia, the patient has lost his rational capacity, but his emotional capacity remains. If the remaining portion of his personality is rooted in his feelings, these feelings should be respected as much as possible. Those involved in the care of the patients who refuse treatment should not force them to undergo it simply on the grounds that it may be an established standard in their own country. What must be asked first is whether or not forced treatment would promote the patient’s subjective well-being. Additionally, treatment decisions should not be distorted due to the selfishness or discriminatory feelings of those involved in his care. In situations in which patients lack decisionmaking capacities, overriding the patients’ refusals of treatment should be regarded as an exception, rather than a standard course of action. Even in patients who are incapacitated, treatment refusal could stem from the feelings of the individual. Their subjective wellbeing would not be improved through close observation, restraint, denial, and coercion, the purpose of which they does not understand. (shrink)

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent''s refusal to provide consent for a child''s medical care. In this paper, I will argue that (...) the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent''s decision to refuse medical care on behalf of a child. (shrink)

We developed this study to examine the issue of parental refusal of treatment, looking at the issue through a cultural competence lens. Recent cases in Canada where courts have declined applications by clinicians for court orders to overrule parental refusal of treatment highlight the dispute in this area. This study analyses the 16 cases of a larger group of 24 cases that were selected by a literature review where cultural or religious beliefs or ethnic identity was (...) described as important reasons behind the refusal. The most significant finding was that nearly all of the cases cited unacceptable side effects as the main reason for declining treatment. We then analysed the detail of the cases and concluded that in the first instance a skilled clinical approach to develop an agreed management plan is by far the best approach. In the event that agreement cannot be reached we recommend engaging a mediator to help the clinician and parents/child to find an agreeable way forward. We argue that the option of se... (shrink)

This paper is an analysis of the limits of family authority to refuse life saving treatment for a family member (in the Chinese medical context). Family consent has long been praised and practiced in many non‐Western cultural settings such as China and Japan. In contrast, the controversy of family refusal remains less examined despite its prevalence in low‐income and middle‐income countries. In this paper, we investigate family refusal in medical emergencies through a combination of legal, empirical and (...) ethical approaches, which is highly relevant to the ongoing discussion about the place of informed consent in non‐Western cultures. We first provide an overview of the Chinese legislation concerning informed consent to show the significance of family values in the context of medical decision‐making and demonstrate the lack of legal support to override family refusal. Next, we present the findings of a vignette question that investigated how 11,771 medical professionals and 2,944 patients in China responded to the family refusal of emergency treatment for an unconscious patient. In our analysis of these results, we employ ethical reasoning to question the legitimacy of family refusal of life‐sustaining emergency treatment for temporarily incompetent patients. Last, we examine some practical obstacles encountered by medical professionals wishing to override family refusal to give context to the discussion. (shrink)

Refusing treatment for potentially curable childhood cancers engenders much discussion and debate. I present a case in which the competent parents of a young Amish child with acute myeloid leukemia deferred authority for decision making to the child’s maternal grandfather, who was vocal in his opposition to treatment. I analyze three related concerns that distinguish this case from other accounts of refused treatment.First, I place deference to grandparents as decision makers in the context of surrogate decision making (...) more generally.Second, the maternal grandfather’s ardent refusal of treatment and his rationale appeared to be inconsistent with the beliefs expressed by other family members and by members of the same Amish community, leading members of the medical team to question whether refusal of treatment should be treated differently when it appears to be based on the idiosyncratic beliefs of an individual rather than on community-wide values.Third, the medical team perceived tension and dissension between the nonverbal behavior of some family members and the verbal statements made by the maternal grandfather, leading the team to question the parents’ true wishes and debate how to weigh nonverbal and indirect forms of communication.Finally, building upon the conclusions of these queries, I explore whether, if the child’s prognosis was less favorable or if he were to relapse later, the maternal grandfather should have been permitted to drive a decision to refuse further treatment. (shrink)

Parental refusal of a recommended treatment is not an uncommon scenario in the neonatal intensive care unit. These refusals may be based upon the parents’ perceptions of their child’s projected quality of life. The inherent subjectivity of quality of life assessments, however, can exacerbate disagreement between parents and healthcare providers. We present a case of parental refusal of surgical intervention for necrotizing enterocolitis in an infant with Bartter syndrome and develop an ethical framework in which to consider (...) the appropriateness of parental refusal based upon an infant’s projected quality of life. (shrink)

This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the ‘AP‐physician‐family‐relationship’ and the dominant role Chinese families play in medical decision‐making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from (...) Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives ‘weak’ family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re‐interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its ‘parens patriae’ power to defend the defenseless in society and the integrity of the medical profession. (shrink)

BackgroundThis case report discusses an ethical communication dilemma in prehospital patient interaction, involving a patient who was about to board a plane at a busy airport. The article argues that the situation raised dilemmas about communication, patient autonomy and paternalism. Paramedics should be able to find good solutions to these dilemmas, but they have not received much attention in the literature on prehospital ambulance work.Case presentationThe patient had chest pains that were consistent with serious heart disease, but she wanted to (...) catch her plane and was unwilling to let paramedics assess her heart activity by means of an electrocardiogram (ECG). The paramedics had to decide, there and then, whether the patient’s refusal to submit to an ECG should be respected, or whether they should set the patient’s expressed wishes aside by exercising verbal power and persuasive communication techniques. The paramedics chose to do the latter. It later turned out that the patient was grateful that the paramedics had been very direct, almost brutal, in their communication. When the patient regained her autonomy, she saw clearly that taking time to obtain and monitor an ECG was the best option for her.ConclusionLooking forward in time might be a good professional strategy for deciding whether ethical paternalism in communication is justified. If there is good reason to believe that patients who later regain their autonomy will agree that paternalistic verbal actions were in their best interests, and if acting in accordance with patients’ preferences can have severe negative health consequences for them, then paramedics have good reason to believe that ethical paternalism is justified. (shrink)

This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the 'AP-physician-family-relationship' and the dominant role Chinese families play in medical decision-making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from (...) Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives 'weak' family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re-interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its 'parens patriae' power to defend the defenseless in society and the integrity of the medical profession. (shrink)

This paper will examine a sample case encountered by ambulance staff in the context of the basic principles of medical ethics.An accident takes place on an intercity highway. Ambulance staff pick up the injured driver and medical intervention is initiated. The driver suffers from a severe stomach ache, which is also affecting his back. Evaluating the patient, the ambulance doctor suspects that he might be experiencing internal bleeding. For this reason, venous access, in the doctor's opinion, should be achieved and (...) the patient should be quickly started on an intravenous serum. The patient, however, who has so far kept his silence, objects to the administration of the serum. The day this is taking place is within the month of Ramadan and the patient is fasting. The patient states that he is fasting and that his fast will be broken and his religious practice disrupted in the event that the serum is administered. The ambulance doctor informs him that his condition is life-threatening and that the serum must be administered immediately. The patient now takes a more vehement stand. ‘If I am to die, I want to die while I am fasting. Today is Friday and I have always wanted to die on such a holy day,’ he says. The ambulance physician has little time to decide. How should the patient be treated? Which type of behaviour will create the least erosion of his values? (shrink)

When there is a conflict between parents and the physician over appropriate care due to an infant whose decision prevails? What standard, if any, should guide such decisions?This article traces the varying standards articulated over the past three decades from the proposal in Duff and Campbell’s 1973 essay that these decisions are best left to the parents to the Baby Doe Regs of the 1980s which required every life that could be salvaged be continued. We conclude with support for the (...) policy articulated in the 2007 guidelines of the American Academy of Pediatrics on non-intervention or withdrawal of intensive care for high-risk newborns. (shrink)

The principal question of this paper is: Why are religious values special in refusal of lifesaving medical treatment? This question is approached through a critical examination of a common kind of refusal of treatment case, one involving a rational adult. The central value cited in defence of honouring such a patient's refusal is autonomy. Once autonomy is isolated from other justificatory factors, however, possible cases can be imagined which cast doubt on the great valuational weight (...) assigned it by strong anti-paternalists. This weight is sufficient, in their estimation, to justify honouring the patient's refusal. There is thus a tension between the strong anti-paternalist's commitment to the sufficiency of autonomy and our intuitions respecting such cases. Attempts can be made to relieve this tension, such as arguing that patients aren't really rational in the circumstances envisaged, or that other values, such as privacy or bodily integrity, if added to autonomy, are sufficient to justify an anti-paternalistic stance. All such attempts fail, however. But what does not fail is the addition of religious freedom, freedom respecting a patient's religious beliefs and values. Why religious freedom reduces the tension is then explained, and the specialness of religious beliefs and values examined. (shrink)

A large part of the debate around the right to refuse life-prolonging treatment of anorexia nervosa sufferers centers on the issue of competence. Whether or not the anorexic should be allowed to refuse life-saving treatment does not depend solely or primarily on competence. It also depends on whether the anorexic’s suffering is bearable or tractable, and on the degree of involvement of the family in the therapeutic process. Anorexics could be competent to refuse lifesaving treatment (Giordano 2008). (...) However, the anorexic’s refusal of life-saving treatment should not be respected purely because it is a competent decision. In fact, anorexia has two characteristics that weaken the strength of the principle .. (shrink)

This paper criticises the current approach of the courts to the problem of patients who refuse life-saving medical treatment. Recent judicial decisions have indicated that, so long as the patient satisfies the minimal test for capacity outlined in Gillick, the courts will not be concerned with the substantive grounds for the refusal. In particular, a 'rationality requirement' will not be imposed. This paper argues that, whilst this approach may accord with our desire to uphold the autonomy of a (...) patient who refuses treatment on religious grounds, it fails to address the problem of the deluded decision-maker whose refusal is based on wrongheaded reasons (and where talk of autonomy is a disservice). The difficulty can be overcome, however, by recognising that the two patients in fact inhabit at distinct realms-the non-rational and the irrational. The test for capacity, at least in the context of life-saving treatment, should revert accordingly to the older concept of 'sound mind', to disallow refusals of an irrational (as opposed to a non-rational) nature. (shrink)

Traditionally, healthcare workers have had the right to refuse to participate in abortions or physician-assisted suicide, but more recently there has been a movement in white Evangelical circles to expand these rights to include the refusal of any treatment at all to same-sex couples or their children, transgender individuals, or others who offend the provider’s moral sensibilities. Religious freedom of conscience exists in an uneasy tension with laws protecting equal rights in a liberal polity, and it is a (...) particularly fraught question in the context of medicine, where providers’ consciences must be balanced against patients’ rights to access appropriate care. This article examines the refusal of care to classes of people, usually classes defined by various sexual issues with which the caregivers disagree. This expands conscientious refusals from the traditional concept of responses to actions and instead directs it at specific types of people. The article draws on Reformed thought to argue that such refusals are not justified and are, in fact, both a profound misreading of Christian morality and a new and dangerously expansive account of the right to conscientious refusal in medicine. (shrink)

Imposing artificial feeding on people with anorexia nervosa may be unethical. This seems to be Heather Draper's suggestion in her article, ‘Anorexia Nervosa and Respecting a Refusal of Life‐Prolonging Therapy: A Limited Justification.’ Although this is an important point, I shall show that the arguments supporting this point are flawed. Draper should have made a brave claim: she should have claimed that people with anorexia nervosa, who competently decide not to be artificially fed, should be respected because everybody is (...) entitled to exercise their autonomy, not only ‘in the middle’ of their life, but also at the end of it, or when their own life is at stake, because autonomy also extends to the most difficult moments of our life, and, ultimately, ‘stretches [.*T*.*T*.] far out into the distance’ at the end of it. I explain why Draper should have made the brave claim, and why she has not made it. I conclude that a defence of people's entitlement to competently refuse artificial feeding cannot rest upon the arguments developed by Draper. Whether or not we should respect competent refusal of artificial feeding depends on the normative strength that we are ready to ascribe to the principle of autonomy, to the moral relevance that we ascribe to the circumstances in which a person's autonomy is exercised, and, perhaps, eventually, on our sense of compassion. (shrink)

The autonomous right of competent adults to decide what happens to their own body and the corresponding right to consent to or refuse medical treatment are cornerstones of modern health care. For minors the situation is not so clear cut. Since the well-known case of Gillick, mature children under the age of 16 can agree to proposed medical treatment. However, those under the age of 18 do not enjoy any corresponding right to refuse medical treatment. Can this (...) separation of the right to agree to treatment and the right to refuse treatment for those under 18, regardless of capacity, be justified? This paper evaluates the key cases in this area of the law. Changes to the current law are then proposed which aim to make the law more consistent and reasonable. (shrink)

That Jehovah's Witnesses cannot refuse life-saving blood transfusions on behalf of their children has acquired the status of virtual “consensus” among bioethicists. However strong the consensus may be on this matter, this article explores whether this view can be plausibly defended on liberal principles by examining it in light of one particularly well worked-out liberal political theory, that of Rawls. It concludes that because of the extremely high priority Rawls attributes to “freedom of conscience,” and the implication from the original (...) position that parents must act paternalistically toward their children as their protectors, Jehovah's Witnesses cannot legitimately be barred from making decisions on behalf of their children, even when the consequences of such decisions are serious and irremediable. (shrink)

May a doctor treat a patient, despite that patient's refusal, when in his professional opinion treatment is necessary? This is the dilemma which must from time to time confront most physicians. An examination of the validity of such a refusal is provided by the present authors who use the case history of a patient refusing treatment, for cancer as well as for a fractured hip, to evaluate the grounds for intervention in such circumstances. In such a (...) situation the patient is said to have a 'false belief' and it is the doctor's duty to try to change that belief in the patient's interest. The false belief is considered here in terms of the liberty principle, the patient's mental competence and on what is called the 'harm principle' (harm to other individuals or to society). Finally the concept of paternalism is examined. The authors conclude that the doctor must attempt to change a false belief, and if this fails he must examine the patient's mental competence to make the decision to refuse treatment. But in the last analysis the doctor may be under an obligation to respect the patient's refusal. Readers might like to look at (or read again) the papers on 'Liberty' and 'Conscience' published in this Journal under the heading Analysis. (shrink)

Injuries from failed suicide attempts account for a large number of patients cared for in the emergency and trauma setting. While a fundamental underpinning of clinical ethics is that patients have a right to refuse treatment, individuals presenting with life-threating injuries resulting from suicide attempts are almost universally treated in this acute care setting. Here we discuss the limitations on physician ability to determine capacity in this setting and the challenges these pose in carrying out patient wishes.

It was not until the nineteenth century that Western nations came to replace mutilation, corporal punishment, and banishment as the favored method of criminal punishment with the more humane concept of imprisonment. Even then, however, a convicted inmate was viewed as nothing more than a slave of the state, entitled only to the most basic of human rights and subject to the whim and peril of his jailor's desire. The shift to imprisonment gradually was accompanied by the additional humanitarian demand (...) that prisons avail their charges of some minimum standard of human decency and necessity, which, by the early part of the twentieth century, had come to encompass the provision of medical care. The courts later came to acknowledge this as a fundamental right grounded in the Eighth Amendment's proscription against cruel and unusual punishments.Although the scope of a prisoner's constitutional right to medical care has been the subject of much debate before the courts, the majority of cases have focused only on the circumstances under which the deprivation of care will amount to a violation of the rights guaranteed by the Eighth Amendment. (shrink)

It was not until the nineteenth century that Western nations came to replace mutilation, corporal punishment, and banishment as the favored method of criminal punishment with the more humane concept of imprisonment. Even then, however, a convicted inmate was viewed as nothing more than a slave of the state, entitled only to the most basic of human rights and subject to the whim and peril of his jailor's desire. The shift to imprisonment gradually was accompanied by the additional humanitarian demand (...) that prisons avail their charges of some minimum standard of human decency and necessity, which, by the early part of the twentieth century, had come to encompass the provision of medical care. The courts later came to acknowledge this as a fundamental right grounded in the Eighth Amendment's proscription against cruel and unusual punishments.Although the scope of a prisoner's constitutional right to medical care has been the subject of much debate before the courts, the majority of cases have focused only on the circumstances under which the deprivation of care will amount to a violation of the rights guaranteed by the Eighth Amendment. (shrink)