An Ethical Response by Physicians?: “When Patients Refuse Assessment of Decision-Making Capacity”

Most times the patient is quite willing and even eager to listen to the physician who is attempting to get informed consent for a procedure or treatment that the physician advises and will make their own decision known followed with an explanation.. The informed consent process is not a one-way communication with the doctor talking to the patient. It requires that the patient communicate his or her understanding of the information to the doctor so that the consent or dissent is validated. But what if the patient wants to be left alone or refuses to communicate and the procedure or treatment is beneficial for the patient’s health? If the patient refuses to explain this behavior or request in spite of the apparent benefit offered, how can the physician evaluate the patient with regard to capacity to make personal medical decisions? What should be the response of the physician? What should happen next? Should the physician assume that the capacity is absent and simply go ahead with the procedure or treatment?

This dilemma of clinical medicine is discussed in an interesting article titled “When Patients Refuse Assessment of Decision-Making Capacity: How Should Clinicians Respond?” by Samia A. Hurst, M.D. in the Archives of Internal Medicine 2004;164:1757-1760. The author concludes the paper with:

“Patients who refuse to explain the reasons for their choice make assessment of their decision-making capacity impossible. I have argued that if a patient who refuses beneficial treatment also refuses to explain why, clinicians should first do their best to engage in a dialogue with the patient, and to try to find others with whom the patient would agree to discuss the reasons. If this is unsuccessful, clinicians should assess the risk to the patient if the patient's wishes are followed. If this risk is significant, they should choose a course of action as if the patient were incompetent. The reasons for choosing this course of action should be explained to the patient as if the patient were competent. This approach neither sacrifices respect for the patient's choices nor care for the patient's best interest. It permits satisfactory resolution of difficult situations with the least possible harm. By outlining a framework for decision making in defined situations, this approach could help prevent decision making from being frozen by the impossibility to assess capacity. More important, it gives clinicians who face such situations the possibility of persisting in their efforts to establish a conversation with their patients.”

You must read the entire article to fully understand the rationale for the conclusion. However, do you think that this approach to the dilemma is ethical, not paternalistic and if not representing patient autonomy it does represent beneficence towards the patient? ..Maurice.