Doctors talk all the time about a patient’s right to refuse treatment. But what about the right to demand it?
Not long ago, a middle-age man was admitted to the hospital where I work with fever and shortness of breath. The man, Eric, was in his early 40s, thin but toned, with colorful tattoos and a pallid countenance.
A chest X-ray showed fluid in his lungs, but doctors did not know why. An echocardiogram, an ultrasound of the heart, provided the answer. On one heart valve was an infected mass of tissue, a vegetation, flapping around wildly like a flag in the breeze. It had severely damaged the valve, resulting in congestive heart failure.
Heart infections can usually be treated with intravenous antibiotics; surgery is reserved for the most complicated cases. In Eric’s case, a CT scan of the head showed several small bleeding sites, probably caused by parts of the vegetation breaking off and lodging in the brain. Doctors decided that the valve needed to be replaced to prevent further injury.
A consulting neurologist recommended an M.R.I. before surgery to make sure that this infection had not caused any brain aneurysms that could rupture and bleed in the operating room, causing a stroke.
When the scan showed no aneurysms, the neurologist asked for a cerebral angiogram to exclude even tiny aneurysms that the M.R.I. might have missed. Though fairly routine, angiograms in rare cases can cause strokes, because a catheter is threaded into the arteries that supply blood to the brain. Eric decided that although he wanted the surgery, he did not want this test.
“You know what I think?” he said to me. “I think they’re just throwing everything at this, and maybe they’ll find something, and then what? They got an M.R.I., and they’re still not satisfied!”
I explained that the doctors were being cautious.
“Hey, I’ll sit here with antibiotics going into me, no problem,” he replied. “But doing a procedure that could cause a stroke? That’s getting a little scary.”
I pulled out my stethoscope so I could listen to his lungs. What if he refused the angiogram, he asked, leaning forward. Couldn’t he have the operation anyway?
I replied that the surgeon would probably not operate without the angiogram, a hunch confirmed the next day.
“But what if I sign a paper accepting the risk?”
The vague outlines of a memory started to form in my mind. “I doubt that’s going to change anyone’s mind,” I said. I told him that if he felt strongly enough, I could arrange for him to be transferred to another hospital.
He did not want to do that. “Oh well, it is what it is,” he said, shrugging, looking resigned. “They’re going to get what they want. It’s a losing battle.”
Though I agreed that an angiogram was needed before surgery, I felt uncomfortable about forcing Eric to do it, given the risks. He had made it clear that he wanted to proceed with surgery without delay or additional testing. He was willing to accept the risks of this approach. But his doctors refused to honor this request.
A patient’s right to self-determination is the prevailing ethic in medicine today, but in reality doctors routinely place limits on it. When a patient’s demand conflicts with a doctor’s moral convictions, ethicists have argued that doctors can deny treatment. For example, gynecologists can refuse to perform abortions because of moral or religious beliefs. Physicians in intensive care units routinely limit treatments they deem futile, especially for terminal illnesses.
But conscientious objection is a relatively rare impetus for denying treatment. A more common situation is when a patient’s request conflicts with what a doctor believes to be good medical practice. In such cases, the objection is over professional, not moral, integrity, though obviously moral questions are raised. In a doctor-patient dispute, who has the right to make the final call? Should doctors just do a patient’s bidding?
I have struggled with these questions from both sides of the doctor-patient relationship. When my wife was pregnant, she needed minor surgery. A surgeon offered us two options. The first posed no risk to our baby but for other reasons was unappealing. The more attractive alternative was slightly riskier, though our obstetrician told us that it was still safe, as long as sufficient oxygen was provided during the procedure. But an anesthesiologist, in pre-operative consultation, said he could not guarantee that would happen.
On the day of the surgery, a few minutes before my wife was to be taken into the operating room, a physician’s assistant demanded that she sign a consent form for the surgery she did not want. When she refused, the anesthesiologist, an imposing man with a bushy salt-and-pepper mustache and bulging eyes, threatened to cancel the operation.
“We would be getting away with something rather than doing the right thing,” he said of the surgical option we had chosen.
I tried to negotiate with him, but he would not budge. “Look, we’ll sign anything you want accepting the risk,” I told him.
He just laughed. “That is not the issue,” he replied. “We want her to be safe.”
“I am not the kind of doctor who says it has to be my way,” he had told us, but in fact, he was.
When I consulted an anesthesiologist at another hospital, she told me that she had polled her colleagues. About half said the procedure we wanted was safe. The remainder agreed with my wife’s anesthesiologist.
How should such disputes be resolved? In 1991, a Minnesota court ruled that the family of Helga Wanglie, an 86-year-old woman in a coma, had the right to demand intensive medical treatment for her, even though her physicians wanted to stop life support because they thought that it was futile. In that judgment, patient (or surrogate) autonomy trumped professional integrity.
Because patients are so dependent and vulnerable, I believe doctors should deny treatment requests only very judiciously — and rarely. A surgeon might understandably refuse to operate on someone whose religious beliefs proscribe blood transfusions, on the ground that she would not want to be forced into medical malpractice.
But in cases with reasonable differences of opinion, where the competing risks are at least debatable, it seems unfair and unwise to deny treatment. Was the reluctant anesthesiologist being virtuous or dogmatic? I’m still not sure. Professional integrity can indeed be a double-edge sword.
In the end, my wife went to another hospital. And Eric stayed and underwent a cerebral angiogram before valve surgery. Fortunately, both operations went well.
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