The issue of refusal of care in medicine is both intellectually difficult and emotionally troubling. To some extent, objective discourse on this topic has been made more difficult because refusal of care in anesthesia is closely associated with the deeply divisive issue of abortion. However, the issue is broader than that and deserves consideration in the context of other factual scenarios. Questions worth considering include: Is it ever appropriate to
refuse anesthesia for a procedure that is legal? If so, who decides when it is appropriate? How should a refusal be invoked?

Arguments regarding the legal and ethical appropriateness of refusals run the gamut from supporting an absolute right of refusal to concluding that no such right exists for any procedure that is legal. The arguments for a right of refusal stem essentially from the American tradition of freedom. After all, this country set forth the right of freedom of expression and religion in its very first Amendment in the Bill of Rights: “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech.” Certainly, it is argued, if one has a right to freedom of religion, and if one’s religious beliefs (or ethical principles) forbid participation in certain procedures, then no one should be able to force one’s participation.

The opposing view is well framed by Dr. Julian Savulescu in a recent issue of the British Medical Fournal (see Suggested Readings). In his article, Dr. Savulescu states that “[w]hat should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources,” and further, that “[i]f people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.” He notes that it is inefficient and inequitable for a large percentage of doctors to refuse to participate in abortions, because patients are then required to “shop” for doctors who will perform a legal service. He further notes that inconsistent moral positions of physicians lead to inconsistent care and discrimination. It could be argued from Savulescu’s thesis that cases of abortion and execution are distinguishable because the abortion is beneficial to the patient whereas execution is not. However, that distinction is likely to be lost on the death-row inmate, who would probably believe it beneficial to be anesthetized by a licensed anesthesia provider before being put to death rather than be sedated by an amateur. If doctors are required to provide any legal, beneficial service requested by patients, could anesthesia providers ethically refuse to provide anesthesia to a death-row inmate who requested to be properly anesthetized before being given a lethal injection? Would the same ethical considerations apply to assisted suicide in a state in which it was legal?