Chapter 10 : Care of the Dying

Author:  Bernard Gert, James L. Bernat, and R. Peter Mogielnicki

Title:  Distinguishing Between Patients’ Refusals and Requests

Publication information:  Hastings Center Report 24, NO. 4 (1994):  13-15. 

Summary by Damali Joseph, Queensborough Community College (2002)

Failure to differentiate obligation of physicians to respond to patients treatment refusals from the obligation of physicians to respond to patients requests for treatment have caused increasing confusion about options accessible to physicians when taking care of capable patients who wish to die, pass on.  The report by The American Medical Association Council on Ethical and Judicial Affairs, “Decisions Near The End of Life” states:

The principle of patient autonomy requires that competent patients have the opportunity to choose among medically indicated treatments and to refuse any unwanted treatment.  Absent countervailing obligations physicians must respect patients decisions.  Treatment decisions often involve personal value judgments and preferences in addition to objective medical considerations.  We demonstrate respect for human dignity when we acknowledge “the freedom [of individuals] to make choices in accordance with their own values.”   

Although the first sentence of this paragraph is presented correctly the remainder of the paragraph states conflict between refusals and requests, which leads to fake conclusions that all decisions and choices made by patients, produce the same responsibility on physicians.  The usage of the words choices and decisions shouldn’t be used because of physician neglect.  The words decision and choice refer to the choosing of alternatives the patient is provided with from the physician and in doing so the doctor is seen as fulfilling the physician-patient obligation.  The same aspects would not apply, if a person who wanted to die due to refusing treatment, voluntary active euthanasia, and physician-assisted suicide.  There are very different aspects in refusal and requests of treatments than in a person who wants to kill themselves such as moral and legal implications.   

If a patient is a rational competent person, a refusal of treatment should be honored but not to the extent of requesting a specific type of therapy.  In the end, the physician has to make the choice based on his professional judgment.  Often times a request is confused with a refusal.   

In the Archives of Internal Medicine there was a survey that showed that 97.7 percent of physicians said they would allow withholding ventilator support if a person dieing requested it and 59.4 percent of physicians said they would turn off a ventilator if a person dieing requested it.  All 100 percent didn’t agree with both aspects even though the patient is rational and competent.  The reason in part for this is there is was no true distinction between a request and a refusal.  These were not requests they were refusals.  Had there been a clear picture of what refusal and request were, the outcome would have been totally different.   

A choice or decision is a refusal only if it is paraphrased as “Leave Me Alone.”  A competent, rational cannot be refused of these rights.  If this were a request it wouldn’t be paraphrased as such.  But according to a report from Hastings Center, not many physicians know that they are legally responsible for honoring a patient’s refusal once they are competent and rational.  The importance of understanding the difference between refusal and request is necessary because it can be seen as killing or just letting someone die.  There also seems to be confusion when using advance directives.  If a patient wants to refuse to eat or drink and refuse treatment, and is sick, it is their legal right to do so.  It is also the physician’s legal obligation, duty, to honor their patient’s demands.     

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