In this interaction, a patient rejected a particular recommendation from his physician. Although the patient continued to see the physician for other matters, he declined a referral to a urologist. Thus, this case explores ethical ideas associated with a patient’s refusal of treatment.
Delayed diagnosis of cancer
Four Basic Principles of Medical Ethics5
- Beneficence — acting for the patient’s good
- Nonmaleficence — doing no harm
- Autonomy — recognizing the patient’s values and choices
- Justice — treating patients fairly
A 50-year-old male patient presented to his family physician (FP) in January with complaints of back and flank pain. Urine tests from that appointment showed trace blood, so the FP told the patient he should see a urologist for follow-up. The physician offered to have his office staff make the referral appointment, but the patient said he would call for an appointment himself. The patient returned to the FP’s office in May with symptoms of an upper respiratory infection. The FP diagnosed a viral infection and recommended the patient use acetaminophen and an over-the-counter decongestant. The FP asked if the patient had seen the urologist. The patient said no. The FP did a repeat urinalysis at this May visit, which again showed trace blood.
The physician called the patient and urged him to follow up with a urologist. The patient declared that he would not go to see a urologist. When the FP asked why the patient was refusing the referral, the patient said he did not want to be catheterized or undergo a prostate exam. The physician discussed the matter further with the patient, encouraging him to see a urologist, advising him of the risks of serious kidney or bladder diseases and emphasizing the importance of getting further assessment of the hematuria. The patient still refused to seek further work-up. The FP documented the discussion.
The patient returned the following February with symptoms of pain and gross hematuria. He finally agreed to see a urologist, and he was subsequently diagnosed with renal cell carcinoma. The patient and his wife then filed a claim against the FP, alleging delayed referral to a urologist and deficient follow-up caused a delay in diagnosis of cancer. In deposition, the patient said that if the physician had been more insistent that he see a urologist, he would have done so earlier, which would most likely have resulted in identification and treatment of the cancer before it reached Stage IV and metastasized to his brain and lungs.
The FP’s documentation of the patient’s visits clearly showed the doctor had tried to convince the patient to see a urologist for further investigation of his symptoms and that the patient had consistently refused a referral. Expert physicians who reviewed the case believed the FP had appropriately informed the patient about the risks of refusing additional work-up by a specialist and that the patient had made an informed refusal decision. The case was ultimately dismissed.
More Information About Medical Ethics and Physician-Patient Encounters
- Closed Claim Case Study: Patient Demand for Unconventional Care Presents an Ethical Dilemma for Physicians
- Closed Claim Case Study: Personal Relationship With a Patient Leads to Below Standard Care
- Closed Claim Case Study: Patient Confidentiality: Understanding the Medical Ethics Issues
- Closed Claim Case Study: Cultural Bias in Health Care Delivery Causes Communication Problems and Poor Outcome
- Closed Claim Case Study: Medical Ethics Issues with Shared Decision-Making in Patient Encounters
- Closed Claim Case Study: Improper Informed Consent Leads to Allegation of Negligent Supervision
- Closed Claim Case Study: Ethical Dilemmas with Disclosing Medical Errors
This is another example of a situation involving tension between autonomy and beneficence. We see this tension in another case as well (see “Patient Demands for Unconventional Care”). In the current case, the patient out-and-out refused care while, in the other case, the patient influenced the physician to modify his recommendation for hospitalization and convinced him to treat her as an outpatient. The cases are also similar in that good, objective documentation by the physician gave a sufficiently clear picture of what happened and allowed the malpractice allegations to be dismissed.
Competent patients have a right to refuse treatment. This concept is supported not only by the ethical principle of autonomy but also by U.S. statutes, regulations and case law. Competent adults can refuse care even if the care would likely save or prolong the patient’s life.1 As Mahowald notes, “Respect for patient autonomy trumps beneficence and nonmaleficence.”2 In this case, the FP did what he could. He fully explained his understanding of the situation, the benefits of obtaining assessment and treatment and the risks of refusal. He sought reasons for the patient’s refusal and had an open discussion using beneficent persuasion to determine if the patient might reframe his attitude and agree to the referral.
Risk Management Recommendations — Interactions in which Patients Refuse Care
- Educate the patient as fully as possible about the benefits of treatment recommendations and the risks of no treatment.
- As much as possible, discover the patient’s reasons for refusing care and discuss these with the patient to see if there are ways to negotiate so that the patient can receive care that is in his or her best interests.
- With the patient’s permission, speak with family, clergy or another mediator if you think this might help the patient reconsider his or her refusal.
- Consider a mental health referral if the patient has overwhelming anxieties about receiving care or shows psychiatric comorbidities and is willing to be evaluated.3
- Consider using “hope and worry” statements to aid in discussion of refusals: “I hope that you don’t have a serious disease, but I worry that your symptoms may indicate serious disease is already present.”4
- Document your efforts to educate the patient, the rationale for your recommended treatment, and the patient’s refusal of care.
- Ask the patient to sign a refusal of care form.
1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:74.
2. Mahowald MB. Bioethics and Women: Across the Life Span. New York, NY: Oxford University Press; 2006:17.
3. Rubin EB. Professional conduct and misconduct. Handbook of Clinical Neurology. 2013;118:91-105.
4. Thomas JD. Ethics case: when patients seem overly optimistic. Virtual Mentor. 2012;14(7):539-544.
5. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press;2012:99-288.