‘While I consider it important to avoid violating the law in my practice of medicine, I consider it even more important to avoid violating principles of biomedical ethics.’

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ACEP News: Vol 32 – No 10 – October 2013

The two principles here are beneficence (the duty to help the patient) and autonomy (the patient’s right to make his own decisions about what happens to him). In the United States (and some other Western societies) autonomy is placed at the top of the hierarchy. This means if one is going to do something that violates patient autonomy, there must be a very good reason. The most common such reason is that the person is mentally ill and intends to harm himself or others. In such a situation, there is agreement that the duty to protect the patient (and possibly others) from harm takes priority over the duty to respect his individual autonomy.

Another common situation is one in which a patient wishes to refuse treatment or to leave a hospital against medical advice. Sometimes such a decision may place the patient in peril of serious harm. So, for example, if someone is having a heart attack, there is a very real risk of sudden death or severe, permanent disability attendant upon a decision to refuse treatment and leave the hospital. But we do not violate the patient’s autonomy and prevent him from leaving, except….

We make an exception for lack of decisional capacity. And to do that we must understand what decisional capacity is and how to assess it.

Let us use the example of the heart attack. If you are having a heart attack and decide to refuse treatment and leave the hospital, my first priority is to try to change your mind. I will explain my treatment recommendations and the risks you are assuming by rejecting them. I will enlist the aid of those whose opinions or feelings mean more to you than mine: your family or friends, or your personal physician. (Maybe even your nurse, because she has impressed you as a warm and caring person, and you have no suspicion that anything she tells you is motivated by pecuniary gain.)

I will try to find out why you want to ignore sound medical advice and whether you have concerns that can be effectively addressed. If you say you cannot stay in the hospital because there will be no one to feed your dog, I will try to figure out how we can get somebody to feed your dog. I will point out that if you die, your dog will be worse off than going hungry for a little while and tell you that in the wild, dogs go for days without eating, and that’s why even domesticated dogs typically eat like they’ve had nothing to eat for a long time, and don’t know when the next meal is coming, every time a bowl of food is put in front of them.