Kara Sears
In the United States, most patients have the right to refuse care for non-life-threatening illnesses. This right is founded on the ethical principle of autonomy, which states that every person has the right to make informed decisions about their healthcare. While this right is considered fundamental, it is not always absolute and can be superseded by the state's interest in preserving life, particularly in the case of children. Additionally, patients who lack decision-making capacity due to altered mental status or intoxication may not have the legal ability to refuse treatment.
| Characteristics | Values |
|---|---|
| Patient's competency | If questionable, information can be given to a legally appointed guardian or a family member designated by the patient to make decisions. |
| Patient's capacity | Patients under the influence of alcohol or drugs may lack the capacity to make their own medical decisions. |
| Patient's age | In the US, patients under the age of 18 do not have the legal right to make medical decisions for themselves and require parental consent. |
| Patient's beliefs | Jehovah’s Witnesses and Christian Scientists may restrict or refuse certain forms of treatment based on their religious beliefs. |
| Patient's finances | Patients may refuse treatment if they believe it is too expensive. |
| Patient's goals and values | Clinicians can respectfully persuade patients to reconsider decisions and explore other appropriate options that align with their goals, but cannot force them to change their mind. |
| Patient advocacy | Patient advocates are trained in patient rights and can help articulate a patient's values, beliefs, and intentions. |
| Parental rights | Parents can refuse treatment for their children if it goes against their religious beliefs, but this is not always the case and may result in criminal prosecution and/or loss of custody. |
| Threat to the community | A patient's refusal of treatment cannot pose a threat to the community, e.g. refusing vaccination for a communicable disease. |
| Threat to life | If refusal of treatment will result in the death of a child, the state's interest in preserving life usually overrides the parents' rights. |
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What You'll Learn
Patient autonomy and informed consent
Informed consent is a cornerstone of medicine, ensuring ethical treatment decisions and patient-centred care. Patients have the right to make informed and voluntary treatment decisions, and this is more than merely signing a document; it is a communication process between the clinician and the patient. This process ensures that the patient is fully informed about the nature of the procedure or intervention, the potential risks and benefits, and the alternative treatments available. The patient can refuse or withdraw consent at any time during treatment. Informed consent promotes trust in the patient-provider relationship and safeguards against unethical practices.
However, patients may feel pressured to consent to treatment due to the unequal power relationship between themselves and their clinicians, making it difficult for them to assert their preferences or ask necessary questions. This issue is especially problematic for vulnerable populations, such as older individuals, those with disabilities, or those facing acute medical conditions. Incarcerated individuals represent a particularly vulnerable population, requiring special consideration due to the limitations on their choices.
When family members disagree with a patient about care planning, the physician might be able to facilitate a resolution. It is common and socially acceptable for a patient to consult family members to aid in decision-making. However, clinicians must be mindful of the potential for family members to become unduly persuasive, manipulative, or coercive. For example, if family members threaten to remove support if the patient does not make the desired decision, the family would be manipulating the patient. In such cases, the physician is obligated to identify this as unacceptable and discuss it with the patient.
In some cases, a patient may lack the capacity to make their own medical decisions, for example, when under the influence of drugs or alcohol, or in the case of psychiatric patients. In these instances, healthcare professionals and/or an institutionally designated ethics committee will make decisions for the patient in the short term, and formal guardianship can be assigned by a court of law if long-term decision-making assistance is required.
In the United States, patients under the age of eighteen do not have the legal right to make medical decisions for themselves and require parental consent for medical care, apart from three major exceptions. Firstly, if the minor has been legally emancipated, they have full medical decision-making power. Secondly, all states recognize a minor's right to seek care without parental consent for any healthcare regarding sexually transmitted infection testing or treatment, pregnancy prevention with contraceptives, and pregnancy/prenatal care. Thirdly, there is a mature minor doctrine, which states that minors who present the intelligence and maturity to make healthcare decisions for themselves can be deemed legally responsible for their own medical decisions.
In summary, informed consent is a critical aspect of patient autonomy, ensuring that patients understand the risks, benefits, alternatives, and potential consequences of medical interventions. This allows individuals to make decisions aligned with their values, beliefs, and preferences, while also protecting clinicians by documenting that patients were adequately informed. Ultimately, informed consent is a tool to enhance patient-centred care and strengthen the clinician-patient relationship through open and honest communication.
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Religious beliefs
In the United States, the First Amendment protects religious belief, but the state may impose restrictions on practice. While the free exercise of religious beliefs is guaranteed, the state can, in certain circumstances, limit religious practices. This is particularly true when the state can demonstrate a compelling interest in the preservation or promotion of health, life, safety, or welfare.
Several courts have upheld the right of an adult to refuse potentially life-saving medical treatment on religious grounds, unless the individual is:
- Mentally incompetent
- The parent and sole provider of young children
- A pregnant woman
In the case of In re Milton, 505 N.E.2d 255 (Ohio 1987), the Ohio Supreme Court observed that:
> the state may not compel a legally competent adult to submit to medical treatment which would violate that individual’s religious beliefs even though the treatment is arguably life-extending.
The court further stated that this holds true no matter how "unwise, foolish, or ridiculous" those beliefs may seem to others.
The right to refuse medical treatment on religious grounds also extends to healthcare providers. The Church Amendments, enacted in the 1970s, protect the rights of individuals and entities to object to performing or assisting in the performance of certain procedures because of their religious beliefs or moral convictions. These provisions prohibit public officials and authorities from requiring recipients of certain federal financial assistance to provide or make their facilities available for abortion or sterilization when the recipient has a religious or moral objection.
However, the right to refuse medical treatment on religious grounds is not absolute. Courts have drawn a distinction between children requiring immediate attention and those needing remedial or elective care. Generally, courts have authorized medical care for children who require immediate life-saving treatment, even when their parents object on religious grounds. In such cases, the child may be removed (at least temporarily) from the parents' custody, and the necessary medical care can be administered.
Additionally, the Code of Medical Ethics states that physicians are expected to provide care in emergencies, honor patients' informed decisions to refuse life-sustaining treatment, and not discriminate against individuals based on personal characteristics.
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Mental capacity
In general, a mentally competent adult has the legal right to refuse medical treatment, even if it causes them serious illness or death. This is based on the ethical principle of autonomy, which states that every person has the right to make informed decisions about their healthcare. Healthcare professionals should not impose their beliefs or decisions on patients and must respect their refusals. However, there are exceptions to this right, such as when the patient is deemed mentally incompetent by a court of law or poses a threat to the community if left untreated.
The assessment of mental capacity can be complex and challenging, especially when dealing with psychiatric patients or individuals under the influence of drugs or alcohol. In such cases, psychiatrists, ethics committees, legal professionals, and the patient's medical team and family may be involved in determining the patient's capacity to make informed decisions about their care. It's important to note that having a serious mental illness does not automatically mean a person is incompetent. As long as the criteria for informed consent can be met, these individuals can make their own decisions unless legally challenged.
In the case of minors, the law varies by state and country. In the United States, patients under the age of eighteen generally do not have the legal right to make medical decisions for themselves and require parental consent. However, there are exceptions, such as when the minor has been legally emancipated or seeks care related to sexually transmitted infections, pregnancy, or contraceptives. The mature minor doctrine also recognises that some minors possess the intelligence and maturity to make healthcare decisions independently.
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Threat to the community
In general, a mentally competent adult has the legal right to refuse medical treatment, even if it causes them serious illness or death. However, there are exceptions to this rule, one of which is when the patient's refusal poses a threat to the community.
A patient's right to refuse treatment is founded on the ethical principle of autonomy, which states that individuals have the right to make informed decisions about their healthcare. Healthcare professionals are ethically and legally required to respect this autonomy and cannot impose their beliefs or decisions on patients. However, in certain situations, a patient's right to autonomy may be overridden to protect the community.
For example, in the case of communicable diseases, mandatory vaccination or quarantine may be necessary to prevent the spread to the general public. This is particularly relevant in school districts, where children may be required to receive certain vaccinations, such as DTaP (diphtheria, tetanus, and pertussis) and MMR (measles, mumps, and rubella), to protect the health of other students and staff. Similarly, immigrants seeking to reside in certain countries may be mandated to undergo specific vaccinations and treatments, such as tuberculosis treatment, to obtain legal status.
In the case of individuals with mental illness or altered mental status due to substances, their right to refuse treatment may be limited if they pose a physical threat to themselves or others. In such cases, clinicians will assess the patient's decision-making capacity, and if they are deemed incompetent or a threat to themselves or the community, treatment may be administered against their wishes. This is also true for psychiatric patients, who may be subject to involuntary hospitalization and treatment if they are a danger to themselves or others.
Additionally, patients who deliberately harm themselves may be detained and treated against their wishes if they lack capacity or qualify for detention under specific mental health legislation. This determination of capacity involves assessing the patient's ability to process information and make informed decisions about their care. If a patient's refusal of treatment is based on religious beliefs, they may still be compelled to undergo treatment if it poses a significant threat to the community.
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Parental rights
Parents have a substantive constitutional right to make decisions concerning their children's care and welfare. However, this right is not absolute and is limited by the state's interest in protecting a child's welfare. While parents generally have the right to refuse medical treatment for their children, this right is restricted in cases where the refusal may endanger the child's life or welfare.
State laws give parents leeway in providing consent for or refusing medical care for their children. However, this is not the case if the decision endangers the child's life. Parents cannot deny life-sustaining treatment or medical care for their children, even if their religious beliefs discourage such treatments. If parents refuse necessary or life-saving care for their child, they may face legal consequences, including criminal prosecution and the loss of custody of the child.
In some cases, the state may intervene to protect the child's welfare. For example, if a child is in physical therapy for seizure activity and developmental difficulties, and the parents discontinue therapy and seek no other treatment, the state may intervene, alleging medical neglect. The court will consider the severity of the medical problem, the likelihood of success of the proposed treatment, and the limited potential harm of the treatment.
The right to refuse medical treatment for religious reasons is also limited. While religious objections to standard medical therapy are often legally valid, this right does not extend to refusing life-saving care that would almost certainly lead to a child's death. For example, courts have decided that parents cannot refuse a blood transfusion for their child based on religious grounds if it is necessary to save the child's life.
In some states, teenagers may have the ability to make their own medical decisions without parental consent. These laws vary by state, and the age of consent for medical procedures can differ, impacting the state's ability to intervene in parental decisions.
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Frequently asked questions
The Patient Self-Determination Act (PSDA) guarantees the right to refuse life-sustaining treatment at the end of life. The PSDA was passed in 1991 and mandated that nursing homes, home-health agencies, and HMOs were required by federal law to respect patients' refusal of care.
All adults with decision-making capacity have the right to accept or decline medical treatment. However, patients under the influence of drugs or alcohol may lack the capacity to make their own medical decisions. In these cases, the law allows for involuntary hospitalization and treatment until the patient is no longer intoxicated.
If a patient is deemed incompetent to make a decision, a legally appointed guardian or a family member designated by the patient can make decisions on their behalf. If no proxy or advanced directive is available, healthcare professionals and/or an institutionally designated ethics committee will make decisions for the patient in the short term.
