Treatment Refusals: Autonomy, Paternalism, and the “Best Interest” of the Patient

Abstract

Closely related to the problems of competency and consent discussed in the preceding chapter is the question of how to handle treatment refusals by patients. It was noted there that an asymmetry exists between the need physicians perceive to assess a patient’s competency to grant consent in the first place and the retrospective assessment of competency once a patient has refused treatment. Put another way, questions of competency usually do not arise when a patient willingly goes along with whatever treatment the physician recommends. It is well known that treatment refusals are often construed as evidence that the patient is incompetent to grant or refuse consent, but that view of the matter is surely mistaken. However competency is to be assessed, it cannot simply be explicated in terms of agreement with what a physician recommends. Even if a patient’s refusal appears irrational, on the face of it, that is still not grounds for assuming that the person is incompetent to choose or refuse a recommended treatment. It is worth recalling that presumptions of incompetency are often made when there is no other evidence of impairment—the patient is not a psychiatric patient, or suffering from senile dementia, or afflicted with a condition that normally impairs cognitive processes.