You cannot treat a patient against his will

Year: 2002

Setting: Gleneagles Hospital, Singapore
Position: Private general practitioner

I am the first and only non-Anglo-Saxon, foreign, private general practitioner in the city-state and the physician of reference for 14 embassies, consulates and a high commission from Europe, Asia, South America and Africa. One afternoon, a nurse comes into my consulting room saying that an ambassador from a European country has had an accident and that he insists on being seen immediately.

I greet him and learn that he has slipped on a wet marble floor and badly twisted his right ankle. I get an X-ray to make sure there is no fracture. Then, because of the severity of the sprain and the intensity of the pain, I recommend a walking cast. He retorts that he will make an appointment with an orthopedic surgeon for this procedure, against my advice. I tried to argue that the longer he waits for the cast to be placed, the longer the recovery time will be, but the patient insists on his own course of action. We bid each other farewell by sharing the latest ex-pat joke. I do not see him in the subsequent weeks and assume, by default, that all is well.

However, about two months later I am attending a function with representatives from the diplomatic corps and I spot him in the crowd, hobbling about with a cane. As I approach, his group, his wife comes to me and makes the following request: “Please don’t be too hard on him. He did not follow your recommendations because he does not want to be seen in a cast.” I have witnessed this kind of behavior before. Some people, when they have reached a prominent social status, refuse to adopt behaviors they think will damage their image. I cannot help but think that, had he allowed me to put his ankle in a cast, he would be happily walking by now, even running if he wanted to. I call the waiter for a cocktail and forget about it by mingling with the crowd.

Lesson for the doctor: You cannot treat a patient against his/her will.

Yann Meunier is the health promotion manager for the Stanford Prevention Research Center who blogs at Scope at the Stanford University School of Medicine.

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  • Rob Lindeman

    Lesson for the blogger: Yes, you CAN treat a patient against his will.  Google “Jared Lee Loughner”

  • Anonymous

    “You can’t treat a person against his will” can be taken in several ways. I believe the sense of the author is that it is akin to the old adage, You can lead a horse to water but you can’t make him drink. A physician can only propose and prescribe and leave the rest up to the patient. Compliance and persistence are beyond the physician’s authority, and rightly so.

    On the other hand, the patient has a duty to some extent to treat himself. The ambassador had a duty for the sake of the country he represented to get well. It is a better image to present himself as rationally treating an injury rather than his predicament later on of hobbling with a cane, which surely looks worse than having a temporary cast. A physician can probe patient resistance (which can be looking for a needle in a haystack) and impress this duty on the patient, and in that sense “force” a patient by marshaling the patient’s own priorities and goals toward treatment rather than against them.

    The cause of Loughner is more complex. Without him being on treatment, it is not clear that he is even competent to make the decision to refuse the treatment that would make him competent. The refusal of treatment might not be his own decision, but his lawyer’s strategy for his legal defense of insanity.

    At any rate, the right to refuse a treatment is not absolute and inviolable and is in theory subject to loss depending on circumstances and especially where the ability to make that decision is hampered. Another example is someone being operated on for some disease and is anesthetized, and in the course of the operation some other urgent but hidden condition is discovered and the surgeon chooses to deal with it rather than wait until the patient can be consulted. What if every unconscious person had to be consulted prior to receiving treatment for the unconsciousness? But if the right to refuse treatment is not absolute and inviolable, then a thankfully rare and exceptional case like Loughner’s might be a legitimate intervention.

    • Rob Lindeman

      “Compliance and persistence are beyond the physician’s authority, and rightly so.”  Agreed, and we can hear the “but” coming!
      “…[T]he patient has a duty to some extent to treat himself.”  Determined on an ad hoc basis, at best, as in the case of the ambassador.  I think, however, presented with the same set of facts, a rational person might disagree that the ambassador’s duty to his country has anything to do with his ankle.

      Regarding your surgery analogy, I’m neither a surgeon nor a ethicist, but my memory of surgical consent forms tells me that there is language that leaves the door open for the actions you describe.  Without them, the patient could claim assault, with justice, in my opinion, even if he benefits from the intervention.

      • Anonymous

        Rob, you’re probably right about the surgical consent extending to previously undetected situations. There is also the likelihood of a surrogate decision maker being consulted, so there would be some consent.

        And I appreciate the nuances you raise regarding the ambassador. Things are certainly up for discussion. But I do stand by my contention that, in a general sense, an ambassador has a duty to get and stay well and to present his country well. In fact, while there may have been some vanity in his decision, it is also ostensibly ordered to how it reflected on his country. I think you’d agree that the role of the physician extends to helping the patient sort out those decisions.

      • Hexanchus t

        Every surgical consent form I’ve seen has some form of catch all boiler plate language along the lines of “or any other procedure the surgeon may deem necessary”.

        That said, the patent still has the right to modify the consent by crossing that out & initialing before they sign the consent if they so choose – at which point the surgeon needs to decide whether to proceed in accordance with the patient’s specific consent to only the original procedure or decline to perform the procedure.

  • Anonymous

    Would amend statement thus:
    “You cannot treat a MENTALLY COMPETENT patient against his/her will.”

  • Deborah Rose

    I don’t know the patient’s culture (European diplomat but lots of unseen personal perceptions are contained in that) – it brings to mind cross cultural issues and the variations that go with it.  There are so many nuances, it’s impossible to know everything about every culture.  Not saying there were cultural issues here, but maybe there were – there were certainly conflicting personal values (that the patient did not share). But how would we know?  The physician above did everything s/he could to inform this patient, so right, we gotta let it go (and document!)  We want to offer the best care for our patients so this is disappointing.  I am always searching for the right questions to ask when I sense resistance – no magic formula.

  • Molly Ciliberti

    No good deed goes unpunished.

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