Ethics of Care Refusal
Medical professionals often face difficult situations when patients refuse care, particularly when that care could be a life-saving treatment. This can be even more complicated when the patient has a mental health condition. Healthcare professionals must consider that while their mental illness could make it harder for an individual to understand their condition, it doesn’t automatically make them incapable of making their own decisions (Wear & Brahams, 1991).
Respecting patient autonomy
A core ethical principle that healthcare professionals must adhere to is respecting the patient’s autonomy; Autonomy refers to an individual’s right to make informed decisions about their own body and treatment. According to Aveyard (2004), competent patients have the right to refuse nursing care, even if their decision contradicts medical advice. This is because individuals are supposed to be the best judges of their own interests, as they can take into account all factors of their life. Additionally, forced treatment can violate personal dignity and integrity, in an environment where it is the duty of healthcare professionals to make them feel heard, and comfortable, and so respecting a patient’s autonomy is strictly necessary. Gross (2005) further elaborates on this point by discussing the Israeli Patient’s Right Act, which limits the circumstances under which force can be used to treat competent patients. This act that supports autonomy emphasizes informed consent and prioritizes the patient’s wishes and not following them could lead to legal implications. However, this approach also introduces challenges, particularly when refusal of care can lead to a deterioration in health.
The duty of care and beneficence
The ethical principle of beneficence in healthcare means that medical professionals must act in the best interests of the patients. However, this duty can often contradict with respecting the patient’s autonomy in the cases where their care refusal could lead to the harm and deterioration of their health. Wear and Brahams (1991) highlight that medical professionals must weigh the potential benefits of treatment against the ethical implications of overriding a patient’s decision. In cases of end-of-life care, Ramesh (2013) argues that prolonging treatment against a patient’s wishes may lead to unnecessary suffering. This perspective supports the notion that the duty of care should also consider the quality of life and respect the patient’s desire to let go when further treatment is futile.
Competence and informed refusal
A significant factor in determining the best course of action upon a patient’s care refusal is the patient’s competence. Competence involves the patient's ability to understand information about treatment options, consider the consequences, and communicate and consistent choice, with well-informed knowledge of their own condition. However, assessing competence can prove to be quite difficult, particularly in psychiatric settings where depression or other mental health conditions may impair decision-making (Rudnick, 2002). When competence is in question, healthcare professionals may need to involve legal or ethical committees to ensure that the patient’s rights are protected while also safeguarding their well-being. This careful assessment will help to balance autonomy with the duty to prevent harm, particularly in vulnerable populations.
Legal and therapeutic implications
Laws about care refusal vary depending on where you are, but most places support a competent adult’s right to refuse treatment. Wear and Brahams (1991) note that while legal systems generally prioritize autonomy, there are exceptions, especially when refusing care could present a significant risk to public health. From a therapeutic standpoint, forcing treatment can damage the trust between a patient and their healthcare provider, which can lead to long-term negative consequences. Aveyard (2004) suggests that open communication and empathy are crucial when dealing with care refusal. By having an honest and understanding conversation, healthcare professionals can sometimes find a way to respect the patient’s wishes while also ensuring their safety. Ultimately the ethics of care refusal encapsulates the duty of medical professionals to maintain a delicate balance between respecting a patient’s autonomy while fulfilling their own professional duty of care, acting in the best interests of their patients. They must consider competence, legal frameworks, and therapeutic relationships to decide the best course of action. They must support patients in making their own well-informed decisions, whilst promoting dignity, respect, and well-being so that they feel comfortable in a healthcare environment.
Written by Shelaa
Moderated by Adelene
References
Aveyard, H., 2004. The patient who refuses nursing care. Journal of Med Ethics, Issue 30, pp. 346-350. Gross, M. L., 2005. Treating competent patients by force: the limits and lessons of Israel's patient's right act. Journal of Med Ethics, Issue 31, pp. 29-34. Ramesh, G. S., 2013. End of life care: should we struggle on, or let go?. Medical Journal Armed Forces India, Issue 69, pp. 2-3. Rudnick, A., 2002. Depression and competence to refuse psychiatric treatment. Journal of Med Ethics, Issue 28, pp. 151-155. Wear, A. N. & Brahams, D., 1991. To treat or not to treat: the legal, ethical and therapeutic implications of care refusal. Journal of medical ethics, Issue 17, pp. 131-135.
