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SURGICAL ETHICS CHALLENGES
Refusal of life-saving treatment in the agedJames W. Jones, MD, PhD,a and Laurence B. McCullough, PhDb
An 85-year-old widower with a dry gangrenous legsecondary to diabetes-related vascular insufficiency re-fuses amputation. You explain the patient’s condition,the nature of the surgery, and prognosis without sur-gery, but he will not consent. You should next:
A. Repeat the informed consent process with the familypresent.
B. Request psychiatric evaluation for competence.C. Ask the patient to explain his decision.D. Seek a court order to amputate.E. Have the patient sign a medical release and prescribe
antibiotics and morphine.
Choice C is the best first response. The remainingmeasures may be ethically defensible along a continuum ofintervention.
During the informed consent process, physiciansshould explain the diagnosis, treatment indications, and thebenefits and risks of a recommended intervention. Thepatient’s right to refuse the suggested treatment is implicitin the process. The patient’s consent can be neither com-manded nor coerced, even when the consequences of non-treatment are known to be life-threatening. The patient canbe asked (but not compelled) to explain his reasons fordeclining a recommended treatment. Because the patient isthe “reasonable person”1,2 for whom the surgeon hasframed his explanations, the physician should try to under-stand the patient’s rationale.
Our patient may believe that the disability and disfig-urement he associates with amputation would destroy thequalities of life he values, outweighing any benefit of ex-tending his already long life. Perhaps he fears that, as hisdisease advances, this will be only the first of many painfuland demoralizing interventions, and he is content to con-clude a full and satisfying life without additional suffering.As a widower, he may fear that he will be unable to care forhimself in his own home, or envision the remainder of hislife in a bleak and joyless nursing home he cannot afford.
He may worry that his long-term care will exhaust thesavings he looks forward to bequeathing his grandchildren.
Choice A, using the family to coerce the patient, shouldbe avoided. The emotional influence of family can beintimidating, particularly to acutely ill and vulnerable pa-tients. Furthermore, family sometimes benefit from a pa-tient’s demise, and conflicts of interest can arise.
Choice B can follow if the patient’s explanation sug-gests that a psychiatric disorder may be influencing hisjudgement. Disagreeing with a physician’s recommenda-tion or declining to extend a life of unremitting pain anddisability are not, in themselves, indications of mental ill-ness. Some of our putative patient’s possible explanationsfor refusing surgery reveal an appropriately apprehensiveperson with intact intellectual function, able to anticipateconsequences and make realistic assessments of competingvalues. When evidence of conditions like major depressionor delusional psychosis emerges during the consent pro-cess, however, psychiatry’s role becomes clear.
Option D presumes before further evaluation by thesurgeon or a psychiatrist that the patient is incompetent tomake rational treatment decisions, abrogating the spirit ofinformed consent. A patient whose only choices are agree-ment or legal compulsion is not giving voluntary consent.Legal intervention may ultimately be sought if psychiatricevaluation suggests mental incompetence and there is norecognized surrogate decision-maker.
Option E may be ethically permissible if the psychiatri-cally intact patient ultimately refuses operative care. Thesurgeon should be afforded protection against later claimsof poor practice, and the patient should be provided withthe medical treatment that offers the best, however slender,possibility of resolving the acute problem. In addition, thesurgeon should discuss the patient’s preferences for end-of-life care and urge the patient to complete advance directivesto document his preferences. The surgeon’s orders shouldimplement the patient’s advance directives. The patientshould be assured that the surgeon will continue to provideexcellent medical care.
REFERENCES1. Faden RR, Beauchamp TL. A history and theory of informed consent.
New York: Oxford University Press; 1986.2. McCullough LB, Jones JW, Brody BA. Informed consent: autonomous
decision making and the surgical patient. In: McCullough LB, Jones JW,Brody BA, editors. Surgical ethics. New York: Oxford University Press;1998. p. 15-37.
From the Department of Surgery, University of Missouri,a and the Centerfor Medical Ethics and Health Policy, Baylor College of Medicine.b
Reprint requests: James W. Jones, MD, PhD, University of Missouri,Department of Surgery (M580), One Hospital Dr, Columbia, MO 65212(e-mail: [email protected]).
J Vasc Surg 2002;35:1067.Copyright © 2002 by The Society for Vascular Surgery and The American
Association for Vascular Surgery.0741-5214/2002/$35.00 � 0 24/1/123691doi:10.1067/mva.2002.123691
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