Chapter 5 Preferences of Patients

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Chapter 5 Preferences of Patients
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Section 1 Competent refusal of treatment

• Persons who are well informed and have decisional
  capacity sometimes refuse recommended treatment.
• Physicians may be confronted with an ethical
  problem
• Does the physicians responsibility to
  help the patient ever override the patients
  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.

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Refusal on grounds of religious or cultural belief

• Case Mr. G. comes to a physician for treatment
  of peptic ulcer. He says he is a Jehovahs
  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
  Jehovahs Witnesses takes this text to prohibit
  transfusion. The physician considers that her
  patients preferences impose on her an inferior
  standard of care. She wonders whether she should
  accept this patient under her care.

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Comment

• 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 patients
  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
  patients belief from the patient and from church
  elders.

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• Is this transfusion necessary?
• 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.

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Recommendation

• Mr. Gs refusal should be respected.

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Irrational refusal of treatment

• 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.

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Comment

• The initial consent for diagnosis was implicit in
  the young mans allowing himself to be brought to
  the ED. The patients 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 patients personal autonomy and the
  paternalistic values that favor medical
  intervention for the patients own good.

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Recommendation

• 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 clinicians knowledge at the time of the
  decision.

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refusal of information

• 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.
• Should the physician override the
  patients 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 patients capacity .

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Advance planning

• 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 ones family and a conference
  with ones doctor.
• The physician will document this conversation in
  the patients 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.

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The limits of patient preferences

• 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.

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World Medical Association International Code of
Medical Ethics

• 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

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DUTIES OF PHYSICIANS TO PATIENTS

• 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.

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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
  patient-physician 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 1968and the
  35th World Medical Assembly Venice, Italy,
  October 1983 and the WMA General Assembly,
  Pilanesberg, South Africa, October 2006

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