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Case Study 2

A competent patient refuses treatment

Mrs X is 35 and is in need of dialysis. She is refusing treatment because she is scared of the treatment which she believes is invasive. She has been counselled about the nature of the treatment - there are no alternatives that would be of practical benefit. She is competent to make treatment decisions. She understands that if she refuses dialysis she will die. She has a daughter of 15 years who lives at home. The clinician feels very strongly that she should receive dialysis but despite numerous attempts to persuade her she refuses.

Can the clinician treat her?

Issues that a clinical ethics committee / group may consider:

Mrs X is competent and so has autonomy to make treatment decisions. If the principle of respect for autonomy is given the highest value then her refusal should be respected despite the resulting harm. It is clear that she considers invasive long term treatment not to be in her best interests.

It is important however that Mrs X is making an informed decision - a decision made in ignorance could not be said to be an autonomous one (although arguably a patient makes an autonomous choice if he delegates his decision to the clinician/ healthcare professional). Mrs X has received dialysis counselling but she still believes it to be invasive. Could more be done to inform her - perhaps she could be taken around a dialysis ward? If she has been sufficiently informed then does she need to make an objectively ‘rational’ decision? This seems unduly paternalistic and not respectful of autonomy which is the expression of individual wishes.

The clinician may feel that he is not acting beneficently towards his patient if he allows her to die for lack of dialysis. In addition, to what extent are the interests of Mrs X’s daughter to be considered? Her exercise of autonomy has enormous repercussions for her daughter - has she been involved in discussions / expressed a view?

Mrs X has been assessed to have capacity. Therefore her refusal must be respected - otherwise a battery may be committed. If through lack of treatment her condition deteriorates and she becomes incompetent through illness, then her previously expressed wishes, made when competent, should be respected.