10 RIGHT TO REFUSE PARTICIPATION IN MEDICAL

RESEARCH
The patient has the right to be advised if the health care provider plans to involve him
in medical research, including but not limited to human experimentation which may be
performed only with the written informed consent of the patient: Provided, That, an
institutional review board or ethical review board in accordance with the guidelines set
in the Declaration of Helsinki be established for research involving human
experimentation: Provided, further, That the Department of Health shall safeguard the
continuing training and education of future health care provider/practitioner to ensure
the development of the health care delivery in the country: Provided, furthermore, That
the patient involved in the human experimentation shall be made aware of the
provisions of the Declaration of Helsinki and its respective guidelines.

Right to Refuse Diagnostic and Medical Treatment

 The Patient has the right to refuse diagnostic and medical treatment procedures,
provided that the following conditions are satisfied;
 The Patient is of legal age and is mentally competent;
 The Patient is informed of the medical consequences of his/her refusal;
 The Patient releases those involved in his care from any obligation relative to the
consequences of his/her decision; and
 The Patient's refusal will not jeopardize public health and safety.

SITUATION:
In this interaction, a patient rejected a particular recommendation from his physician.
Although the patient continued to see the physician for other matters, he declined a
referral to a urologist and medical treatment. Thus, this case explores ethical ideas
associated with a patient’s refusal of treatment.
CASE
A 50-year-old male patient presented to his family physician (FP) in January with
complaints of back and flank pain. Urine tests from that appointment showed trace
blood, so the FP told the patient he should see a urologist for follow-up. The physician
offered to have his office staff make the referral appointment and give him a medical
treatment for his situation, but the patient said he would call for an appointment himself.
The patient returned to the FP’s office in May with symptoms of an upper respiratory
infection. The FP diagnosed a viral infection and recommended the patient use
acetaminophen and an over-the-counter decongestant. The FP asked if the patient had
seen the urologist. The patient said no. The FP did a repeat urinalysis at this May visit,
which again showed trace blood.

The physician called the patient and urged him to follow up with a urologist. The patient
declared that he would not go to see a urologist. When the FP asked why the patient
was refusing the referral, the patient said he did not want to be catheterized or undergo
a prostate exam. The physician discussed the matter further with the patient,
encouraging him to see a urologist, advising him of the risks of serious kidney or
bladder diseases and emphasizing the importance of getting further assessment of the
hematuria. The patient still refused to seek further work-up. The FP documented the
discussion.
The patient returned the following February with symptoms of pain and gross hematuria.
He finally agreed to see a urologist, and he was subsequently diagnosed with renal cell
carcinoma. The patient and his wife then filed a claim against the FP, alleging delayed
referral to a urologist and deficient follow-up caused a delay in diagnosis of cancer. In
deposition, the patient said that if the physician had been more insistent that he see a
urologist, he would have done so earlier, which would most likely have resulted in
identification and treatment of the cancer before it reached Stage IV and metastasized
to his brain and lungs.

The FP’s documentation of the patient’s visits clearly showed the doctor had tried to
convince the patient to see a urologist for further investigation of his symptoms and that
the patient had consistently refused a referral. Expert physicians who reviewed the case
believed the FP had appropriately informed the patient about the risks of refusing
additional work-up by a specialist and and refusal of medical treatment that the patient
had made an informed refusal decision.

DISCUSSION
This is another example of a situation involving tension between autonomy and
beneficence. We see this tension in another case as well. In the current case, the
patient out-and-out refused care while, in the other case, the patient influenced the
physician to modify his recommendation for hospitalization and convinced him to treat
her as an outpatient. The cases are also similar in that good, objective documentation
by the physician gave a sufficiently clear picture of what happened and allowed the
malpractice allegations to be dismissed.

Competent patients have a right to refuse treatment. This concept is supported not only
by the ethical principle of autonomy but also by U.S. statutes, regulations and case law.
Competent adults can refuse care even if the care would likely save or prolong the
patient’s life.1 As Mahowald notes, “Respect for patient autonomy trumps beneficence
and nonmaleficence.”2 In this case, the FP did what he could. He fully explained his
understanding of the situation, the benefits of obtaining assessment and treatment and
the risks of refusal. He sought reasons for the patient’s refusal and had an open
discussion using beneficent persuasion to determine if the patient might reframe his
attitude and agree to the referral.

RISK MANAGEMENT RECOMMENDATIONS — INTERACTIONS IN

WHICH PATIENTS REFUSE CARE
 Educate the patient as fully as possible about the benefits of treatment
recommendations and the risks of no treatment.
 As much as possible, discover the patient’s reasons for refusing care and
discuss these with the patient to see if there are ways to negotiate so that the
patient can receive care that is in his or her best interests.
 With the patient’s permission, speak with family, clergy or another mediator if you
think this might help the patient reconsider his or her refusal.
 Consider a mental health referral if the patient has overwhelming anxieties about
receiving care or shows psychiatric comorbidities and is willing to be evaluated. 3
 Consider using “hope and worry” statements to aid in discussion of refusals: “I
hope that you don’t have a serious disease, but I worry that your symptoms may
indicate serious disease is already present.”4
 Document your efforts to educate the patient, the rationale for your
recommended treatment, and the patient’s refusal of care.
 Ask the patient to sign a refusal of care form.
ASSIGNMENT
IN
BIOETHICS

SUBMITTED BY:
OCHO, SHERYL
CEPEDOZA, RYME

SUBMITTED TO:
MRS. CONCHI MANHILOT

BSN II – RUBY