When Patients Refuse Best Treatment

Editor’s Note: In the field of health science, we may sometimes encounter people and patients whose beliefs conflict with our own, or situations may arise that test our moral compass. Sometimes, there may not be a black and white answer to what’s right or wrong. This new column seeks to delve into these murky grey areas by engaging our brains and hearts in conversations about making hard choices. Each column will feature a new question with answers from a broad swathe of the UCSF community. Please join the conversation by sharing your thoughts through comments, social media, or emailing the authors directly.

Welcome to our new ethics column! We’re two writers from the dental organization SPEA (Student Professionalism and Ethics Association), and we want to explore what the humans of UCSF think about different ethical dilemmas in healthcare. In each installment, we’ll be focusing on a different dilemma. These questions will stem from problems we or others have seen first-hand in our experiences with healthcare. We hope to bring you a variety of opinions from different fields and gather input from our audience. Want to participate?! Read to the end and you could be featured in the next installment!

Today’s questions is: “What would you do if a patient refused a treatment or procedure that was determined to be necessary for their care due to personal, religious or other reasons? For example, a patient needs a painful procedure, but refuses anesthesia because of religious beliefs. How would you fulfill your duties as a healthcare provider without violating the patient's rights to autonomy over his/her care?”

Kara Kang, a second year pharmacy student, had some very thoughtful input: “A patient's individual volition ought to be upheld, no matter how potentially unpalatable to us as providers… Look no further than your friendly neighborhood anti-vaxxer. I would give the best care that my patient consents to, without incurring any harm.

“I'd treat my patient's values and beliefs as if they were a contraindication or exclusion from treatment.

“Say our case patient's anesthesia-requiring surgery was due to an infection, and our next best treatment was antibiotics and supportive care. I would get them exactly that, plus a heaping spoonful of patient education and legal disclaimer… If you feel uncomfortable with the care you are able or unable to provide, help your patient find a provider who is willing to treat them.”

In the case of a procedure requiring anesthesia, second year dental student Monica Armendariz agrees with Kara, saying she would ultimately respect the patient’s wishes: “If they can handle the pain and complete the procedure, props to them and they are a true champ! If they change their mind because they can’t handle it, I’ll gladly anesthetize them.”

Dr. Michael Le, DDS also agrees, but notes that sometimes these conflicts can put patients in greater danger than just pain: “If delay of treatment puts the patient at risk to life-threatening complications… I would strongly encourage the patient to find a way to reconcile their beliefs [with a method of treatment]… I have presented all options in the best interest of the patient (beneficence), been fair (justice), and been honest in my capabilities of fulfilling that care (non-maleficence).

“I have to respect the autonomy of the patient because all treatment, no matter how necessary, is always elective.”

Finally, civilian input from Steven Ramsay, a Biology teacher in Sacramento. He sums it up nicely: “I think a health care provider needs to inform the patient of the consequences of their decision and the reasons why the treatment is necessary. If the patient still refuses, they should have to sign a document acknowledging their refusal of treatment that clearly states in writing the consequences of refusal. This way the health care provider has done everything they can to help the patient make an informed decision and also respect the right of the patient to choose.”

Have a different opinion? Want to share your thoughts for the next installment? Want YOUR ethical dilemma answered by UCSF? Here’s your chance! Please send us any comments, questions, or answers by emailing anna.nonaka@ucsf.edu, or engaging us through comments on the website or our social media pages.

Answer our next ethical conundrum: “Do you think everyone deserves access to free healthcare? Some countries have free healthcare systems, but citizens are taxed for it and the quality of healthcare is often called into question. Is this fair to everyone? Are compromises worth the universal coverage?” Email us and share your thoughts!