Ethical Implications

In Western medical ethics, respect for patient autonomy holds a predominant place governing physician actions. Before the 20th century, physicians relied on a paternalistic ethical framework, in which the physician, and not the patient, determined what constituted the patient’s “best interests,” and the determination of best interest generally rested in decisions favoring preservation of life. Throughout the 20th century, however, cultural changes as well as legal precedents shifted the weight of decision making from the physician to the patient. The emphasis of ethical medical care was not “preservation of life,” per se, but rather preservation of quality of life. Thus patient consent for care, and in particular informed consent, became the cornerstone of both ethical and legal values in medical practice.

Respecting autonomous patient wishes also serves the second principle in medical ethics—that of beneficence, or “doing good.” By respecting the wishes of Jehovah’s Witness patients, the physician demonstrates respect for their spiritual beliefs and their prioritization of a goal of a good spiritual life after death. Furthermore, the physician avoids participating in harm to the patient’s spiritual well-being.

What if respecting the patient’s beliefs would cause a physician to violate his or her own moral principles? Can physicians become “conscientious objectors”? Physicians can and do sometimes argue that it is against their personal moral beliefs to not administer available lifesaving therapy if it is available, and that refusal of blood transfusions (and other common lifesaving medical therapies such as cardiopulmonary resuscitation) violates the physician’s moral “rights.” However, physicians have a special “social contract” with their patients—one that affords the physician significant societal privilege in return for putting the interests of a competent patient above their own interests, and the moral rights of patients above their own.

Physicians are generally aware of these obligations to patients, and do have the choice to not enter medical practice or to avoid specialty areas of medical practice in which their own moral principles will be violated. In addition, they are often able to avoid specific patient relationships that might violate personal ethics. But allowing individual physician ethics to routinely supersede general principles of medical ethics would challenge the very integrity of medical philosophy within the medical profession as a whole. A physician is not allowed to proceed without informed consent, for example, just because he or she does not believe it is an important principle. Society has placed top priority on the rights of consent and refusal, and physicians serve a facilitating role in society. Many anesthesia practices have policies recognizing that strongly held personal moral beliefs may be anticipated and conflicts avoided with foresight and planning. To the degree that options can be offered to the practitioner in a timeframe that still allows appropriate patient care, physicians may ethically remove themselves from patient care in favor of another practitioner who does not have personal moral objections. Thus practices often allow for some practitioners to “opt out” of abortion procedures, for example. Unfortunately, time does not always offer such options, and the physician is obligated to provide care that is broadly morally required in ethical medical care, rather than force their individual moral beliefs on their patients.

Legal Considerations

Federal law and legal precedents support the rights of competent patients to refuse lifesaving transfusions, although there are some exceptions. The landmark case of Schloendorff v. Society of New York Hospital in 1914 determined that “every person of adult years and sound mind has a right to determine what shall be done to his own body.” These rights are based in constitutional guarantees of privacy and noninterference.

The cases of Karen Ann Quinlan and Nancy Cruzan involved comatose patients whose surrogate decision makers wanted to discontinue life-sustaining treatments. The New Jersey State Supreme Court and the U.S. Supreme Court, respectively, found that rights grounded in the 14th amendment of the constitution allowed patients to refuse such therapies. The U.S. Congress passed the Patient Self-Determination Act of 1990 and established in federal law the rights of patients to refuse any medical therapy (see Box 7.1 in Chapter 7 ), including life-sustaining therapy. The more recent case involving Terri Schiavo, a woman in a persistent vegetative state whose husband wanted to discontinue tube feedings, demonstrated the durability of this constitutional right.

Adult Competent Patients

If an adult patient with decision-making capacity is informed of the relevant risks and refuses certain aspects of medical care, both ethical principles and legal precedents weigh heavily in their favor, even if their life is at stake.

Adult Incompetent Patients

Respect for patient autonomy acknowledges that competent patients may declare decisions they have made about potential future health care issues that might arise when they are incompetent and/or unable to express their wishes. Living wills, do-not-resuscitate decisions, transfusion refusals, and organ donation constitute advance directives that are ethically and legally recognized as the patient’s own voice. Surrogate decision makers may make decisions for incompetent patients under many circumstances, and many states have established legal hierarchies describing who can make and express such decisions on behalf of the patient ( Box 26.1 ).

BOX 26.1

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  Durable Power of Attorney for Health Care Decisions

  
  
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  Conservator or guardian having authority to make health care decisions

  
  
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  Spouse or domestic partner

  
  
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  Adult son or daughter, or adult children as a group if unanimous

  
  
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  Custodial parent or parents if unanimous

  
  
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  Adult siblings if unanimous

  
  
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  Adult grandchildren if unanimous

  
  
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  Other available adult relative with closest degree of kinship to the patient

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