Medical Ethics: Doctor-Patient Relationship And The Right To Refuse Treatment

Karen's Case: Refusing a Life-Saving Surgery on Moral Grounds

Question:

Discuss about the Medical Departement ?

Karen, a 33-year-old woman has been suffering with paranoid schizophrenia. She developed a delusional belief that she has no children when in real she had a daughter. She was diagnosed with ovarian cancer during her medical tests, although the doctor was not sure enough about the cancer. Doctor Green advised her to undergo a total abdominal hysterectomy without which she will not survive for more than six months. If the surgery is performed then chances are high that she will live for about three or five years. Karen refuses to undergo the surgery, as she wants to conceive. Her parents support the doctor but she believes that her parents are against her decision to have children with her boyfriend, Liam. Karen and Liam believe that her guardian angels said she has no cancer and herbal medicines can cure her completely.

Adrian, Karen’s 15 years old brother is suffering from facial and neck infection and is advised by his doctor to complete the course of the medicine or else it may either lead to sepsis or become fatal. Being animals’ rights group member, he refuses to take the medicinal pills as his mother said that those pills are tested on animals. His mother, Fiona, being an animals’ rights activist herself supported his decision while his father, Charlie, wanted him to undergo the treatment.

Can Karen refuse to undergo the treatment on the ground of moral beliefs?

Is Adrian legally capable to refuse the treatment?

Can a doctor compel a patient to undergo any treatment?

The doctor-patient relationship forms the basis of medical ethics. It constitutes an essential element for delivering proper healthcare while treating the patients. The guidance on the ‘Consent: patient and doctor making decision’ together have been laid down in the General Medical Council (GMC). It sets out the principles to take good medical decisions.

As stated in paragraph 18 of the GMC, it is important for a doctor to discuss with the patient the detailed information about the diagnosis and the treatment options. The doctor must communicate the information in such a manner that the patient understands and retain it. If needed, other healthcare team members may be consulted during the discussion. If the information is of complex nature or the proposed treatment involves considerable amount of risks, the patient must be given time to make necessary decisions.[1]

According to paragraph 19, if the doctor proposes a particular type of treatment, the doctor must give necessary reasons to support his proposal. The doctor must not pressurize the patient to accept the proposal or the advice, whatsoever.

While discussing with the patients about the amount of risks involved in the proposed treatment, the doctor must also communicate the consequences in case the patient refuses to take any action. The consequence of not taking any action may sometimes result in death.[2]

According to paragraph 43, if the patient refuses any proposed treatment, the doctor must respect the decision taken by the patient irrespective of the fact whether the decision taken is wrong or unreasonable. The doctor in such situation is required to explain the patient about the consequences of the decision taken. However, if even then the patient refuses the treatment, the doctor must not compel the patience to accept his advice.[3]

Adrian's Case: Minor's Right to Refuse Treatment

As per the principle laid down in paragraph 47, if the patient gives consent to a proposed treatment and the treatment involves greater amount of risks, the consent of the patient must be obtained in writing.

It must not be assumed that adult patients are capable of taking decisions relating to any examination, treatment, or investigation.[4] It can be presumed that a patient is incapable of taking decisions if even after providing detailed information about the treatment and consequences, the patient is unable to comprehend the same,(Para 64). There are patients who are capable of taking uncomplicated decisions but the difficulty arises when the nature of the decision is complicated or it involves several options. Some patients are unable to take proper decisions owing to the fluctuating condition which prejudices their ability to comprehend or retain the information communicated, (Para 66).[5]

According to the principle laid down in paragraph 74 of the GMC, in case the doctor is not sure about the patient’s capacity to take decisions, he must seek legal advice in order to ask the court to determine the capacity of the patient. Where there arise any disagreements, the doctor should consult concerned authorities and the legal framework for resolving disagreements.[6]

In Re C(Adult, refusal of treatment)[1994]1 All ER 819, C was paranoid schizophrenic and was being treated in Broadmoor hospital. His leg was affected with gangrene and doctors advised amputation of his affected leg, which was considered pertinent to safeguard his life. He refused the treatment and the Court upheld his decision. The case lays down the theory that mental sickness does not essentially put a patient’s capability to make decisions into question. Patients who are capable of comprehending and evaluating the required information are free to accept or reject treatment, even if those decisions turns out to be irrational to the doctor or even fatal for the patient.

The decisive capacity of a young person relating to the approval of medical treatment depends largely on their capability to comprehend and evaluate the existing options rather on their age.[7] A young person aged 16 years is assumed to possess the ability to make most of the decisions relating to their treatment and care as laid down in paragraph 55.

In Gillick v West Norfolk and Wisbech AHA [1986] AC 112, it was observed that children are competent to assent or refuse to medical treatment if the maturity level of the child is adequate to comprehend the procedure and the consequences of the proposed cure.[8]

In case the patient is a child and lacks ability to make an appropriate decision and both the parents of the child refuses the proposed treatment on the grounds of some moral beliefs or religious beliefs, the doctor is required to discuss about their concerns and try to reach out for alternate options for treatment, which will assimilate their beliefs.[9] Notwithstanding, providing the child and his parents with the detail information about the proposed treatment, the consequences and the availability of the alternate options, the doctor is unable to reach to an agreement and the treatment is pertinent to safeguard the life of the patient, the doctor should approach the court.[10]

Guidelines for Obtaining Informed Consent and Respecting Patients' Autonomy

In an emergency or in any exceptional circumstances, where it becomes an absolute necessary to treat the patient in order to preserve his life or prevent deterioration in health, the doctors must apply the needed treatment even against the wishes of the parents of the patient.[11]

According to paragraph 57 of the GMC, if the condition of the patient is such:

• it will have an effect on the time-span or quality of their life or
• it will deteriorate the health,
• it is predictable that there is a possibility of suffering loss or impairment of his capability to make decisions,

The doctors are required to encourage them and discuss their issues with them or consult with the healthcare team members.[12] Patients may discuss about their fears relating to the treatment and beliefs of the patient that are likely to influence the decisions of the patient.[13]

In the present case, Karen is a patient of paranoid Schizophrenia. Paranoid schizophrenia is the most common form of schizophrenia, which causes the person to have false beliefs or delusions. For instance, patient may believe something even though there is evidence that it is false or that some persons are conspiring against them or their family. The schizophrenic disease is a chronic condition that lasts through out the life of an individual’s life.[14] Karen had a daughter but being a schizophrenic, she was under the false belief that she has no children.

Karen is being treated at the Blagton NHS Trust for her stomach problems and during her medical tests, a tumor was found and she was diagnosed to be suffering from ovarian cancer. Although the doctor, Dr. Green was not sure enough if the tumor was cancerous. Dr. Green advised her to go through a surgery or else she will not survive for more than 6 months. She will have to undergo total abdominal hysterectomy, as it will enhance the time-span of her life to 3 to 5 years. Karen resentfully refused to undergo the surgery even against her parent’s wish. Here, Karen is a patient of paranoid schizophrenia so she is under a false belief that her parents are plotting to prevent her from conceiving any children with Liam, as they disliked him. As one of the effects of schizophrenia, she was forgetful and was always under a delusion that her parents were conspiring with the doctor against her. She is under an illusion that her guarding angels said that herbal medicines could cure her completely.

According to the principles under the guidance of the GMC, a doctor is advised to communicate to the patient about the amount of risks involved in the proposed treatment.[15] If even after providing sufficient information the patient does not give his consent, the doctor cannot force the patient to accept the advice irrespective of the fact that his decision is wrong or irrational. Para 66 of GMC states that a patient’s consent depends largely, on the patient’s condition.

The surgery of Hysterectomy involves removal of uterus including the cervix to remove all visible ovarian cancer cells. Although Karen is suffering from a chronic disease but she is competent enough to comprehend the treatment and its repercussion. After surgery, Karen was aware that she would not be able to conceive children still she is desperate to have children and hence, determined about not undergoing the surgery. As laid down in the case Re C [1994], patients having the capacity to retain and evaluate the required information are capable of making decisions about refusing medical treatment. Although being a schizophrenic patient, her general capacity is impaired, it is established that she understands the purpose the effects of her treatment. It is advisable that Dr. Green does not force her to accept his advice and respect her decision of not undergoing the surgery even if it appears to him to be illogical and may put her life and health, both at risk.

Karen’s 15-year-old brother was suffering from facial and neck infection. He is also being treated at the Blagton NHS Trust and his doctor, Dr. Ramjan advises him to take a course of pills, which will cure him completely. He refuses to take the pills as the pills are tested on animals and he himself being a member of the animals’ right group refused to gain at the cost of the animals. The doctor advised him that if the pills are not taken the infection might lead to sepsis or result in serious illness and even death. Adrian’s father, Charlie, wanted him to continue the treatment, as he was worried that the scars on his face would become permanent and make it worse.

The legal framework set out in the GMC lays down that at the age of 16, persons are considered as adults and are assumed to have capacity to make decisions. Children who are below the age of 16 are not considered as adults and their capacity to make decisions depends upon their level of maturity and understanding. When a competent child refuses medical treatment, the authority of the persons with parental responsibility is required or the court may overrule the decision of the child.[16] Adrian has refused the treatment on the ground of moral belief that since the pills are tested on animals, he does not want to affect the animals for his own benefit. Consent is valid if a person who is capable of giving consent gives it voluntarily. If a child below 16 years refuses to assent the treatment, the court can overrule his decision if it would result in death or any permanent injury. The court that is approached to resolve issues relating to what would be beneficial to the patient is the Court of Protection.[17]

If a child below the age of 16 is competent enough to understand, retain and weigh the nature or purpose or effect of the treatment, additional consent of the parents is not required.[18] However, if such decision tends to jeopardize the life of the child, then the consent of the parents is required. If a parent refuses to give consent for the treatment, the court can overrule the decision if it is of the opinion that it would be for the benefit of the child.[19]

Here, Fiona, Adrian’s mother supported his decision to refuse the treatment whereas his father, Charlie, wanted him to continue the treatment. If one of the parents of the child gives consent to perform the treatment and another parent does not, then the doctor shall accept the consent and proceed with the treatment.[20] If both the parents refuse to give consent, then the court shall intervene and overrule the decision keeping in view the welfare of the child as the primary concern.

Adrian’s mother did not give her consent to perform the treatment but his father did give his consent, as he was worried that if the treatment is not performed the infection may jeopardize his life. Since one of the parents has given consent, Dr.Ramjan may proceed with the treatment.

Conclusion

A patient has a right to refuse medical treatments if he is competent to make such decision and it is the duty of a doctor to respect the decision even if it results in death of the patient. In case a child below 16 years refuses treatment, the parents or the court may overrule such decisions if it is for the child’s benefit.

Reference list

Blake, Peter, et al. "Principles and Guidelines for Informed Choice and Consent: for all Health Care Providers and Planners." Journal of Manual & Manipulative Therapy (2013).

Bourne, Tom, et al. "Doctors' experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data." BMJ open 6.7 (2016): e011711.

Cave, Emma. "Goodbye Gillick? Identifying and resolving problems with the concept of child competence." Legal studies 34.1 (2014): 103-122.

Coggon, John. "Mental Capacity Law, Autonomy, and best Interests: An Argument for Conceptual and Practical Clarity in the Court of Protection." Medical Law Review 24.3 (2016): 396-414.

Coleman, Doriane Lambelet, and Philip M. Rosoff. "The legal authority of mature minors to consent to general medical treatment." Pediatrics 131.4 (2013): 786-793.

General Medical Council (Great Britain). Good medical practice. General Medical Council, 2013.

Jackson, Emily. Medical law: text, cases, and materials. Oxford University Press, 2013.

Lamont, Scott, Yun-Hee Jeon, and Mary Chiarella. "Health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to treatment An integrative review." Nursing ethics 20.6 (2013): 684-707.

Larcher, Vic, et al. "Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice." Archives of disease in childhood 100.Suppl 2 (2015): s1-s23.

Lee, Albert. "Bolam’to ‘Montgomery’is result of evolutionary change of medical practice towards ‘patient-centred care." Postgraduate Medical Journal (2016): postgradmedj-2016.

Mason, Kenyon, Graeme Laurie, and Alexander McCall Smith. Mason and McCall Smith's law and medical ethics. Oxford University Press, 2013.

Mullick, Anjali, Jonathan Martin, and Libby Sallnow. "Advance care planning." BMJ 347.7930 (2013): 28-32.

Owen, Gareth S., et al. "Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study." The British Journal of Psychiatry 203.6 (2013): 461-467.

Peabody, Francis W. "The care of the patient." Jama 313.18 (2015): 1868-1868.

Scott, Ian A., et al. "Difficult but necessary conversations—the case for advance care planning." Med J Aust 199.10 (2013): 662-6.

Senn, B., et al. "Developing and evaluating complex interventions: the new Medical Research Council guidance." Studies 59 (2013): 587-592.

Smithson, Elizabeth, et al. "Are we following the guidelines for consenting? Prospective audit to determine whether the general medical council and department of health guidance on consent is being followed in an inner city hospital." International Journal of Surgery 11.8 (2013): 667.

Speer, Susan A., and Elizabeth Stokoe. "Ethics in action: Consent?gaining interactions and implications for research practice." British Journal of Social Psychology 53.1 (2014): 54-73.

Weisz, George, ed. Social science perspectives on medical ethics. Vol. 16. Springer Science & Business Media, 2012.

Wright, Christine, et al. "Multisource feedback in evaluating the performance of doctors: the example of the UK General Medical Council patient and colleague questionnaires." Academic Medicine 87.12 (2012): 1668-1678.

[1]General Medical Council (Great Britain). Good medical practice. General Medical Council, 2013.

[2]Mason, Kenyon, Graeme Laurie, and Alexander McCall Smith. Mason and McCall Smith's law and medical ethics. Oxford University Press, 2013.

[3]Smithson, Elizabeth, et al. "Are we following the guidelines for consenting? Prospective audit to determine whether the general medical council and department of health guidance on consent is being followed in an inner city hospital." International Journal of Surgery 11.8 (2013): 66

[4] Weisz, George, ed. Social science perspectives on medical ethics. Vol. 16. Springer Science & Business Media, 2012.

[5] Wright, Christine, et al. "Multisource feedback in evaluating the performance of doctors: the example of the UK General Medical Council patient and colleague questionnaires." Academic Medicine 87.12 (2012): 1668-1678.

[6] Speer, Susan A., and Elizabeth Stokoe. "Ethics in action: Consent?gaining interactions and implications for research practice." British Journal of Social Psychology 53.1 (2014): 54-73.

[7] Jackson, Emily. Medical law: text, cases, and materials. Oxford University Press, 2013.

[8] Cave, Emma. "Goodbye Gillick? Identifying and resolving problems with the concept of child competence." Legal studies 34.1 (2014): 103-122.

[9] Blake, Peter, et al. "Principles and Guidelines for Informed Choice and Consent: for all Health Care Providers and Planners." Journal of Manual & Manipulative Therapy (2013)

[10]Owen, Gareth S., et al. "Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study." The British Journal of Psychiatry 203.6 (2013): 461-467.

[11]Mullick, Anjali, Jonathan Martin, and Libby Sallnow. "Advance care planning." BMJ 347.7930 (2013): 28-32.

[12] Senn, B., et al. "Developing and evaluating complex interventions: the new Medical Research Council guidance." Studies 59 (2013): 587-592.

[13] Lamont, Scott, Yun-Hee Jeon, and Mary Chiarella. "Health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to treatment An integrative review." Nursing ethics 20.6 (2013): 684-707.

[14]Peabody, Francis W. "The care of the patient." Jama 313.18 (2015): 1868-1868.

[15] Lee, Albert. "Bolam’to ‘Montgomery’is result of evolutionary change of medical practice towards ‘patient-centred care." Postgraduate Medical Journal (2016): postgradmedj-2016.

[16] Bourne, Tom, et al. "Doctors' experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data." BMJ open 6.7 (2016): e011711.

[17] Coggon, John. "Mental Capacity Law, Autonomy, and best Interests: An Argument for Conceptual and Practical Clarity in the Court of Protection." Medical Law Review 24.3 (2016): 396-414.

[18] Larcher, Vic, et al. "Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice." Archives of disease in childhood 100.Suppl 2 (2015): s1-s23.

[19] Coleman, Doriane Lambelet, and Philip M. Rosoff. "The legal authority of mature minors to consent to general medical treatment." Pediatrics 131.4 (2013): 786-793.

[20] Scott, Ian A., et al. "Difficult but necessary conversations—the case for advance care planning." Med J Aust 199.10 (2013): 662-6.