This pilot study explores the reasons patients have for refusing chemotherapy, and the ways oncologists respond to them. Our hypothesis, generated from interviews with patients and oncologists, is that an ethical approach that views a refusal as an autonomous choice, in which patients are informed about the pros and cons of treatment and have to decide by weighing them, is not sufficient. A different ethical approach is needed to deal with the various evaluations that play a role in treatment refusal. (...) If patients forgo further treatment, while curative or palliative methods are available, there is no perspective from which to integrate the weighing of pros and cons of treatment and the preferences and values of individual cancer patients. A discrepancy thus results as regards what “good reasons” are, evoking misunderstandings or even breaking off communication. Suggestions are given for follow up research. (shrink)

The purpose of this paper is to analyse the concept of 'best interest' in order to give nurses, who use it to justify their actions, a clear picture of what this means, and to identify the skills needed for doing so. The process for concept analysis developed by Walker and Avant was used in the analysis of data generated from the literature. Themes were identified from which the defining attributes, antecedents and consequences emerged. The congruence of the findings with current (...) values in nursing, such as promotion of patient autonomy, and the nurse as advocate, are discussed, together with the underpinning ethics theory. The skills needed for nursing practice are identified and recommendations for nurse education are made. (shrink)

Objective: To gain insight into the standards of rationality that physicians use when evaluating patients’ treatment refusals.Design of the study: Qualitative design with indepth interviews.Participants: The study sample included 30 patients with cancer and 16 physicians . All patients had refused a recommended oncological treatment.Results: Patients base their treatment refusals mainly on personal values and/or experience. Physicians mainly emphasise the medical perspective when evaluating patients’ treatment refusals. From a medical perspective, a patient’s treatment refusal based on personal values and experience (...) is generally evaluated as irrational and difficult to accept, especially when it concerns a curative treatment. Physicians have a different attitude towards non-curative treatments and have less difficulty accepting a patient’s refusal of these treatments. Thus, an important factor in the physician’s evaluation of a treatment refusal is whether the treatment refused is curative or non-curative.Conclusion: Physicians mainly use goal oriented and patients mainly value oriented rationality, but in the case of non-curative treatment refusal, physicians give more emphasis to value oriented rationality. A consensus between the value oriented approaches of patient and physician may then emerge, leading to the patient’s decision being understood and accepted by the physician. The physician’s acceptance is crucial to his or her attitude towards the patient. It contributes to the patient’s feeling free to decide, and being understood and respected, and thus to a better physician–patient relationship. (shrink)

Treatment of sick children of Jehovah's Witness and Christian Scientist families at times presents significant dilemmas to American medicine and ethics, for modern healthcare professionals rely heavily on active treatment, and withholding of some treatments is a central religious tenet for Witnesses and Scientists. In important instances, physicians, nurses, ethicists, and courts may wish to set aside traditional religious beliefs and values when medical values support treatment to which adherents of these sects at times object.

This paper criticises the current approach of the courts to the problem of patients who refuse life-saving medical treatment. Recent judicial decisions have indicated that, so long as the patient satisfies the minimal test for capacity outlined in Gillick, the courts will not be concerned with the substantive grounds for the refusal. In particular, a 'rationality requirement' will not be imposed. This paper argues that, whilst this approach may accord with our desire to uphold the autonomy of a patient who (...) refuses treatment on religious grounds, it fails to address the problem of the deluded decision-maker whose refusal is based on wrongheaded reasons (and where talk of autonomy is a disservice). The difficulty can be overcome, however, by recognising that the two patients in fact inhabit at distinct realms-the non-rational and the irrational. The test for capacity, at least in the context of life-saving treatment, should revert accordingly to the older concept of 'sound mind', to disallow refusals of an irrational (as opposed to a non-rational) nature. (shrink)

This paper describes the concept of a do-gooder: a person who does unwanted good. It illustrates why doing-good is a problem and argues that patients should not be compelled to do what is best. It shows the ways in which doctors covertly do-good and offers a critique of these. The discussion focuses on the example of the treatment of patients who attempt suicide.

Requests by patients or their families for treatment which the patient's physician considers to be "inappropriate" are becoming more frequent than refusals of treatment which the physician considers appropriate. Such requests are often based on the patient's religious beliefs about the attributes of God (sovereignty, omnipotence), the attributes of persons (sanctity of life), or the individual's personal relationship with God (communication, commands, etc). We present four such cases and discuss some of the basic religious tenets of the three Abrahamic faith (...) traditions as they relate to such requests. We suggest that religious reasons for requesting "inappropriate" treatment are "special" and deserve serious consideration. We offer guidance to assist clinicians and clinical ethicists as they attempt to resolve these conflicts, emphasising the importance of understanding the religious beliefs of the patient/surrogate and suggesting the assistance of a religious interpreter. We suggest open discussion with patients and families of both the clinical situation and the theological basis for these requests. We also suggest that clinicians use additional religious doctrines or principles from patients' own traditions to balance the reasons behind the requests. We conclude that most persistent requests for "inappropriate" treatment should be honoured. (shrink)

Savulescu maintains that our paper, which encourages clinicians to honour requests for "inappropriate treatment" is prejudicial to his atheistic beliefs, and therefore wrong. In this paper we clarify and expand on our ideas, and respond to his assertion that medicine, ethics and atheism are objective, rational and true, while religion is irrational and false.

In their recent article, Erbay et al considered whether a seriously injured patient should be able to refuse treatment if the refusal was based on a (mis)interpretation of religious doctrine. They argued that in such a case ‘what is important…is whether the teaching or philosophy used as a reference point has been in fact correctly perceived’ (p 653). If it has not been, they asserted that this eroded the patient's capacity to make an autonomous decision and that therefore, in such (...) cases, it is the role of the healthcare professional (HCP) to ‘assist patients to think more clearly and rationally’ (p 653). There are, however, a number of problems with the reasons why Erbay et al suggest we should help patients to rationalise their decisions and how HCPs should go about this. In this article, the author explores some of their main arguments regarding consent and rationality (particularly in relation to religious beliefs), as well as Erbay et al's normative claim that HCPs have an obligation to promote autonomy by helping patients to come to a ‘rational’ decision. Ultimately, the author agrees that the (temporary) solution to the dilemma presented in this scenario (which was to insert an intravenous cannula into the patient in order to allow an infusion of fluids in the event that he changed his mind) seemed both pragmatic and ethically permissible. However, it is suggested that the arguments which underpin this conclusion in Erbay et al's article are largely unsound. (shrink)

Patient requests for “inappropriate” medical treatment based on religious beliefs should have special standing. Nevertheless, not all such requests should be honored, because some are morally disturbing. The trouble lies in deciding which ones count. This paper proposes criteria that would qualify a religious belief as medically valid to help physicians decide which requests to respect. The four conditions suggested are that the belief is shared by a community, is deeply held, would pass the test of a religious interpreter and (...) does not harm others. (shrink)

This article critically re-examines the application of the principle of patient autonomy within bioethics. In complex societies such as those found in North America and Europe health care professionals are increasingly confronted by patients from diverse ethnic, cultural, and religious backgrounds. This affects the relationship between clinicians and patients to the extent that patients' deliberations upon the proposed courses of treatment can, in various ways and to varying extents, be influenced by their ethnic, cultural, and religious commitments. The principle of (...) patient autonomy is the main normative constraint imposed upon medical treatment. Bioethicists typically appeal to the principle of patient autonomy as a means for generally attempting to resolve conflict between patients and clinicians. In recent years a number of bioethicists have responded to the condition of multiculturalism by arguing that the autonomy principle provides the basis for a common moral discourse capable of regulating the relationship between clinicians and patients in those situations where patients' beliefs and commitments do or may contradict the ethos of biomedicine. This article challenges that claim. I argue that the precise manner in which the autonomy principle is philosophically formulated within such accounts prohibits bioethicists' deployment of autonomy as a core ideal for a common moral discourse within multicultural societies. The formulation of autonomy underlying such accounts cannot be extended to simply assimilate individuals' most fundamental religious and cultural commitments and affiliations per se. I challenge the assumption that respecting prospective patients' fundamental religious and cultural commitments is necessarily always compatible with respecting their autonomy. I argue that the character of some peoples' relationship with their cultural or religious community acts to significantly constrain the possibilities for acting autonomously. The implication is clear. The autonomy principle may be presently invalidly applied in certain circumstances because the conditions for the exercise of autonomy have not been fully or even adequately satisfied. This is a controversial claim. The precise terms of my argument, while addressing the specific application of the autonomy principle within bioethics, will resonate beyond this sphere and raises questions for attempts to establish a common moral discourse upon the ideal of personal autonomy within multicultural societies generally. (shrink)

In a recent Journal of Medical Ethics article, ‘Should Religious Beliefs Be Allowed to Stonewall a Secular Approach to Withdrawing and Withholding Treatment in Children?’, Joe Brierley, Jim Linthicum and Andy Petros argue for rapid intervention in cases of futile life-sustaining treatment. In their experience, when discussions of futility are initiated with parents, parents often appeal to religion to ‘stonewall’ attempts to disconnect their children from life support. However, I will argue that the intervention that the authors propose is culturally (...) insensitive. (shrink)

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist (...) appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle. (shrink)

This dissertation explores conflicts between religion and medicine, cases in which cultural and religious beliefs motivate requests for inappropriate treatment or the cessation of treatment, requests that violate the standard of care. I call such requests M-requests (miracle or martyr requests). I argue that current approaches fail to accord proper respect to patients who make such requests. Sometimes they are too permissive, honoring M-requests when they should not; other times they are too strict. I propose a phronesis-based approach to decide (...) whether to honor an M-request or whether religious beliefs are medically valid. This approach is culturally sensitive, takes religious beliefs seriously, and holds them to a high ethical standard. This approach uses a principle of belief evaluation developed by Linda Zagzebski: The Principle of Rational Belief, which is founded upon Aristotelian virtue ethics. In addition to the Principle, I propose a concrete set of conditions to assist caregivers in clinical case evaluations. In the final chapters, I apply the phronesis-based approach to well-known adult cases such as the refusal of blood transfusions by Jehovah’s Witnesses and requests for continued (futile) care by Orthodox Jews at the end of life. Also, I consider cases involving children such as African female circumcision and cases of faith healing. I argue that The Principle of Rational Belief should define the threshold of the kinds of M-requests for children that can be honored, but I allow a lower threshold for M-requests made by competent adult patients. (shrink)