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Health Care Ethics USA Requests for Inappropriate Treatment: Can A Doctor "Just Say 'No'"?
In the 1980s, Nancy Reagan invoked the nation to "Just say 'no'." Practicing medicine in the 21st Century would be far simpler if doctors could simply take her advice when responding to requests for inappropriate treatment. Alas, they cannot. Instead, the reason for the request must be discerned, and a discussion must take place about why the physician and the patient or decision maker disagree. Like the requests themselves, such conversations are a relatively new phenomenon. Before the 1970s, it was accepted that doctors practiced medicine paternalistically: the doctor knew best. There were relatively few treatment choices to consider. Since then, however, the stunningly rapid development of medical technology and the ascendance of the bioethical principle of autonomy, have changed the dynamics of the patient/physician relationship in regard to treatment choice. While now clearly and appropriately stated in law and ethics that a competent patient has the right to be fully informed, and to consent to or refuse treatment, somewhere along the way some patients have assumed a right not only to accept or refuse offered treatment, but to demand from medical professionals whatever treatment they desire. They seem to consider doctors and other health care professionals as skilled contractors, paid to do as they are told. This phenomenon is facilitated by the fact that physicians are no longer the only source of medical information. Today's patients arrive at the doctor's office or the hospital already well-versed about products they have learned about on television, through advertisements, or at the "Google School of Medicine." They arrive with strongly held preconceived notions of what they want done, before even hearing the doctor's treatment recommendations. Others just want anything and everything done to keep themselves or their loved one alive. Whatever the reasons, doctors continue to be confronted with requests for inappropriate treatment. Practical Considerations This raises two important questions that the doctor must reflect upon, which are the focus of this discussion: (1) Why do the patient and I disagree? and (2) How should I respond? To answer the first question, the doctor must give careful consideration to why the request seems inappropriate. Here, rather than getting bogged down in the philosophical marshland of debate about futility, it is quicker and more direct in a clinical setting to determine, as suggested by Canadian bioethicists Charles Weijer, et al, whether the proposed treatment would be (a) ineffective, or (b) effective, but toward a controversial end.1 Ineffective Treatment If the doctor believes the treatment would be ineffective - and here he or she can engage the empirical criteria often used in determining quantitative futility (e.g., useless in the last 100 cases,2 or unable to be systematically reproduced) - then there is no legal or ethical obligation to provide the treatment. Indeed, if the doctor believes the treatment to be against the best interest of the patient, as in causing gastrointestinal distress by introducing or continuing medically assisted nutrition and hydration (and particularly so if requested by a proxy decision maker and not the patient) the physician has an ethical obligation not to deliver the treatment. What remains is only a duty to explain clearly why the treatment would be ineffective, and to continue effective care. Effective Treatment Toward a Controversial End Effective treatments that support controversial ends are akin to those sometimes referred to as "qualitatively futile." In the physician's judgment, they will not reverse or ameliorate the patient's condition. That goal of improving the patient's condition is the value that grounds the physician's belief that the treatment is inappropriate. Controversy arises when the patient or decision maker argues from a different value. In these cases, the doctor needs to determine the nature of that value. If it is found in cultural or religious concerns, does the end that the patient or family seeks simply differ from what is familiar to the doctor and the local community, or does it actually conflict with accepted ethical values and/or norms? Do ethnic or socioeconomic conditions give rise to the differences? Does guilt or denial on the part of the patient or family cause them to demand what the doctor feels is inappropriate treatment? At this point, the physician would be wise to call on sources from the patient's family, faith, or community to assist in working through the controversy. It may be that the physician will ethically have to cede that while the end that is sought still seems inappropriate, it has sufficient validity to others to be respected. Conclusion If the doctor remains ambiguous about whether to refuse to provide effective treatment toward a controversial end, he or she might consider the following questions: (1) Would agreeing to this treatment conflict with my obligation to act in the best interest of my patient? and (2) Would agreeing to this treatment conflict with my primary obligation to "First, do no harm?" If the answer to those questions is "no," the patient's request should probably be honored. Answering "yes" to either indicates that ethically, the doctor should seriously consider declining. If after such consideration the doctor concludes that providing the treatment would violate his or her personal integrity, there is strong justification for refusing. The patient's autonomy does not include the power to demand action that would violate the doctor's ethical integrity. Nevertheless, the doctor may not abandon the patient, but continue care until another can be found, if that is the path sought by the patient or family. As in all cases of disagreement between health care providers and patients, successful resolution of requests for inappropriate treatment requires conscientious and honest conversation with the patient: It can be ethical to say "no," but never to just say "no." 
Ann Suziedelis, PhD Suggested Readings R.D. Orr and L.B. Genesen, "Requests for "Inappropriate" Treatment Based on Religious Beliefs," Journal of Medical Ethics, 23(1997):142-147. William E. Novotny, Ronald M. Perkin, and Robert D. Orr, "Faith-based Decisions: Parents Who Refuse Appropriate Care for Their Child," AMA Virtual Mentor 5 (August 2003), at http://www.ama-assn.org/ama/pub/category/10811.html
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