I remember the first time a patient’s poor medical decision relieved me. Mr. Smith (name changed here and throughout), a 20-something rumored drug dealer, had been hospitalized for months while recovering from a gunshot wound. We treated his wound with a vacuum-assisted closure (VAC). He was on total parenteral nutrition as general and plastic surgery worked to get his wound closed. The staff rotated him through the wards because of his behavioral issues, including repeatedly spitting at nurses.
A senior resident and I met Mr. Smith while on plastic surgery rounds, where our primary role involved changing the wound VAC. As we entered Mr. Smith’s room, he shouted that he wasn’t going to let us touch him that day. We exited quickly, and I felt lucky for avoiding an interaction with a challenging patient. I knew that Mr. Smith’s refusal of the wound VAC was a bad medical decision, but I felt ethically justified in accepting it out of respect for his autonomy. The speed with which we departed his room made me mildly uncomfortable, but I shook it off and continued on with rounds.
A few days later, I saw Ms. Jones, another patient who needed a VAC change, and like Mr. Smith, she initially declined it. But this time, I discussed with the patient the potential consequences of not treating her wound—the risk of infection, sepsis, and possibly death. I didn’t accept her decision at face value. Instead, I worked to get her to understand why she stood to benefit from the treatment. Ultimately, despite her discomfort, she consented, and her wound healed.
I could not ignore the contrast between how I handled the two cases.
Autonomy is one of the four essential principles of medical ethics, along with beneficence, non-maleficence, and justice . While this may seem an ancient concept, it is not; prior to World War II, the primary value was benevolence, and it often was delivered with a heavy dose of paternalism. Following the “Doctors’ Trial” in Nuremburg, Germany, which resulted in the execution of several Nazi orthopaedic surgeons for cruel and criminal human experiments , voluntary consent became a bedrock principle of medical research , and subsequently, of all medical care .
Although the four principles of medical ethics seem like they should work together harmoniously, in practice they inevitably conflict, and in Western medical practice, autonomy often dominates over the other three principles. Many American medical students first encounter the preeminence of autonomy in case studies about Jehovah’s Witnesses whose decisions to decline blood products on religious grounds are respected (principle of autonomy) over life-saving alternatives (which would seem beneficent) .
The principle of autonomy requires physicians to respect “bad decisions” if patients are making them free of controlling influences and with some level of understanding . Yet, I think such an acceptance of a “bad” decision in an autonomous patient may be ethically unacceptable if the physician hasn’t first established respect for the person making the decision. While it may be impossible for a physician to respect the decisions made by the patient, such as my difficulty in respecting the rumored behavior of drug dealing, I failed by not first valuing the patient as a human being, without conditions or judgment.
I believe that my ethical lapse in caring for Mr. Smith was that I was too enthusiastic in allowing him to decline care that clearly would have benefited him. The fact that I had more respect for Ms. Jones caused me to push her—even over her initial objection—in the direction of accepting care that I thought she should receive. I found myself troubled by this distinction, and in retrospect I now know why. I treated patients differently based on my level of respect for them, and that is wrong. When Mr. Smith refused the VAC change, I felt relieved, and in retrospect, I believe I used the principle of patient autonomy as a useful excuse to extricate myself from an unpleasant situation.
I would argue that respecting autonomy is insufficient for physicians; a broader view of respect is required, beyond seeing a person as competent or not to make autonomous decisions.
Mary Catherine Beach MD, MPH, a colleague of mine at the Johns Hopkins Berman School of Bioethics, has written on a broader view of respect for persons . Dr. Beach believes that “the type of respect that physicians owe to patients is independent of a patient’s personal characteristics, and therefore, ought to be accorded equally to all … the respect that we promote has both a cognitive dimension (believe that patients have value) and a behavioral dimension (acting in accordance with this belief)” .
How would this broader view of respect for persons play out in clinical practice? I propose a simple mechanism. If a patient is refusing beneficial care and you find yourself relieved or thankful, pause and consider whether you would accept such a refusal of care from a cherished friend or family member. If you would accept such a refusal easily and without further discussion, it is likely that you respect both the person and his or her autonomy. If, on the other hand, you wouldn’t easily accept the refusal of care if it came from a family member or friend, then doing so likely represents a failure to respect the person rather than a respect for his or her autonomy.
It is difficult to choose to spend more time with challenging patients, but to respect their autonomy in an authentic way, this is exactly what we need to do. I am no better at this than anyone else; often, the amount of time I want to spend with a patient is inversely proportional to the amount of time I ought to spend with him or her if the goal is truly to respect both the patient and his or her autonomy. But based on my experience with Mr. Smith, and the processing I’ve done on the interaction since it occurred, if I find myself relieved to leave the room after a patient has refused treatment, I pause and return to the bedside to invest more in the relationship, as I would do if the patient were my friend, and as I ought to have done with Mr. Smith.
1. Beach MC, Duggan PS, Cassell CK, Geller G. What does ‘respect’ mean? Exploring the moral obligation of health professionals to respect patients. J Gen Int Med. 2007;22:692-695.
2. Beauchamp TL, Childress J. The Principles of Biomedical Ethics.
New York, NY: Oxford University Press; 2012.
3. Bock GL. Jehovah's Witnesses and autonomy: Honouring the refusal of blood transfusions. J Med Ethics. 2012;38:652-656.
4. Faden RR, Beauchamp TL. A History and Theory of Informed Consent. New York, NY: Oxford University Press; 1986.
5. Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law. The Nuremberg Code. Washington, D.C.: U.S. Government Printing Office, 1949. Available at: https://history.nih.gov/research/downloads/nuremberg.pdf
. Accessed October 24, 2018.
6. United States Holocaust Memorial Museum. The doctors’ trial: The medical case of the subsequent Nuremberg proceedings. Available at: https://www.ushmm.org/information/exhibitions/online-exhibitions/special-focus/doctors-trial
. Accessed October 22, 2018.