Clinicians’ judgment may trump patients’ legal rights
MedWire News: Physicians vary widely in how they interpret patients' right to refuse treatment, possibly reflecting the complex legal situation, a survey of Norwegian doctors indicates.
For the study, 640 specialist physicians completed a questionnaire that addressed hypothetical scenarios involving decisions on end-of-life care. The case in question was an autonomous 45-year-old patient with amyotrophic lateral sclerosis who was refusing ventilatory treatment.
"According to Norwegian law, an autonomous patient has the right to refuse life-prolonging treatment," explain Marianne Bahus (Centre for Medical Ethics, University of Oslo) and fellow study authors writing in Resuscitation. "If the patient is not defined as dying, however, health personnel are obliged to instigate life-saving treatment in an emergency situation even against the patient's wishes."
The physicians were selected at random from the membership of the Norwegian Medical Association and included specialists in internal medicine, pediatrics, surgery, neurology, and neurosurgery.
In all, 406 of the respondents had real-life experience of end-of-life decisions, and 394 doctors expressed an opinion on the hypothetical patient's right to refuse life-prolonging treatment.
Overall, 56.1% of doctors said that the patient always has the right to refuse such treatment, 42.4% said that a patient can normally refuse treatment, and 1.5% said that the patient cannot refuse.
Interestingly, responses varied by specialty, such that neurologists and surgeons were much more likely than pediatricians to believe that patients "can always refuse treatment." This may reflect the fact that different laws govern pediatric patients, note the authors, whereby the opinion of the healthcare system supercedes that of the parents.
Just 89 doctors (22.5%) said that respecting the patient's decision to refuse treatment did not pose a problem.
One remarked: "If the patient is clear and oriented I suppose he can always refuse, but there will probably be exceptions too," while another added a caveat: "Provided that you have been treating the patient for a long period, and you know that the patient has really made up his mind and, not least that his quality of life is getting worse."
A further 22 doctors (5.6%) said that the patient's decision would be incorporated into their "global clinical judgment" and 14 (3.6%) said that they would wish to have a further discussion with the patient "so that the patient is given the chance to change his mind."
Another doctor observed that there will always be uncertainty about whether the patient had fully understood the consequences of both options - ie, accepting versus refusing treatment.
Commenting on their findings, Bahus et al say that doctors' emphasis on the importance of patient autonomy varies, and there is a gap between legal and ethical reasoning in this and similar scenarios "whereby the autonomous views of a patient may be ignored and overridden."
"These findings indicate that doctors place great moral emphasis on their own clinical judgment, and less emphasis on the patient's legal rights," the authors conclude.
By Joanna Lyford