Violation of the Patient’s Autonomy?: Is that Ethical?
Patient autonomy is the ethical principle which represents that a patient who has the capacity to understand their medical condition and the risks and benefits of some action upon them, has the ethical right, under most circumstances, to make that decision for themselves and expect the physician to abide with their request.
But that is “under most circumstances”. I want to present two scenarios where a patient has stated “stop! I don’t want…” The question I pose to my visitors is whether a physician can ignore that request in each of the scenarios and if so why or why not should the patient’s request be followed or not followed. When do standards of medical practice trump a patient’s request? Standards of medical or surgical practice are specific behaviors, based on scientific literature but also based on the consensus of physicians about certain diagnostic or therapeutic actions and also on common behaviors or actions of doctors where they practice and which the profession of medicine place upon physicians as the physicians carries out their care of their patients. In this regard, if there is a difference between the two cases, what is the difference? ..Maurice.
Scenario 1:
Brain surgery of lesions is often performed on conscious patients to establish safe dissection around motor and sensory areas. A patient with skull opened and brain exposed demanded the surgeon to stop the operation at once despite understanding the consequences of fully terminating the surgery at this point and leaving the skull open. Instead of stopping, the surgeon had the patient anesthetized to allow proper closure of the skull thus was violating the patient's demand. Is what the surgeon did ethical?
Scenario 2:
An adult Jehovah’s Witness patient because of acute massive bleeding which cannot be rapidly stopped requires life saving blood transfusion but is awake and refuses blood transfusions based on the patient’s religion. The patient is informed that with the transfusion, the patient will live and the underlying bleeding problem can be resolved with no long term medical consequences. Without the transfusion, the patient could most likely die. The patient still refuses but the physician, as the patient is beginning to lose consciousness, violates the patient’s autonomous demand and begins the blood transfusions. Is what the physician did ethical?
posted by Maurice Bernstein, M.D. @ 5:01:00 PM
2 comments
2 Comments:
I see no way a surgeon could ethically leave a skull open and a brain exposed- despite what the patient might be saying under stressfull circumstances...
The Jehovah Witness/ blood question seems more complex- although we might not agree with their belief about blood products- I am inclined to say we should respect/honor that belief...
thank you for your postings..
In scenario 1, I assume the surgeon had no indication prior to surgery that the patient might request termination. The patient is in a traumatic situation, and his judgment may be influenced by the circumstances. I think what the surgeon did was ethical.
In scenario 2, I would need more details on the situation to decide. The most difficult scenario would be that the patient came into an emergency room, the physician had never seen the patient before, there were no patient records, and, in particular, the patient had not previously signed an advance directive with regard to transfusions. I actually think it would be ethical for the physician to allow the patient to die in that situation, assuming the patient is not a minor.
If the patient was admitted to a hospital and this happened during the patient's stay, then someone would be at fault for not having clarified in advance how to handle the possibility of this event. Prior to surgery, for example, a Jehovah's Witness can be informed of the risks and can state quite clearly that he or she is prepared to die rather than receive a transfusion. It would not be unethical to allow such a patient to die when the circumstances have been anticipated. I suspect, however, that most surgeons would not want to operate on such a patient.
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