Article Text

Download PDFPDF

A case study from the perspective of medical ethics: refusal of treatment in an ambulance
  1. Hasan Erbay1,
  2. Sultan Alan2,
  3. Selim Kadıoğlu1
  1. 1Department of Deontology and History of Medicine, Cukurova University, Adana, Turkey
  2. 2Cukurova University Adana Health High School, Department of Midwifery, Adana, Turkey
  1. Correspondence to Dr Hasan Erbay, Cukurova University, Department of Deontology and History of Medicine Balcali Kampusu 01330 Yuregir, Adana, Turkey; hasanerbay{at}yahoo.com

Abstract

This paper will examine a sample case encountered by ambulance staff in the context of the basic principles of medical ethics.

An accident takes place on an intercity highway. Ambulance staff pick up the injured driver and medical intervention is initiated. The driver suffers from a severe stomach ache, which is also affecting his back. Evaluating the patient, the ambulance doctor suspects that he might be experiencing internal bleeding. For this reason, venous access, in the doctor's opinion, should be achieved and the patient should be quickly started on an intravenous serum.

The patient, however, who has so far kept his silence, objects to the administration of the serum. The day this is taking place is within the month of Ramadan and the patient is fasting. The patient states that he is fasting and that his fast will be broken and his religious practice disrupted in the event that the serum is administered. The ambulance doctor informs him that his condition is life-threatening and that the serum must be administered immediately. The patient now takes a more vehement stand. ‘If I am to die, I want to die while I am fasting. Today is Friday and I have always wanted to die on such a holy day,’ he says.

The ambulance physician has little time to decide. How should the patient be treated? Which type of behaviour will create the least erosion of his values?

  • Quality/value of life
  • informed consent
  • right to refuse treatment
  • moral and religious aspects

Statistics from Altmetric.com

Introduction

In Turkey, the official medical emergency dispatch system that manages health calls and the dispatching of ambulances is the hotline ‘112’. This study will examine an incident between a patient who is making a decision and ambulance staff to render this patient emergency medical intervention, from the perspective of medical ethics.

The event

On Friday, 26 September 2008, an accident occurs on the intercity highway. Onlookers call 112. According to the information they supply, there is one injured person involved in the accident. The 112 control centre dispatches the closest ambulance team to the scene of the accident.1 The injured person is the driver of the vehicle, travelling alone. The driver has been removed from the vehicle with the help of persons from passing cars and he is conscious. Having arrived at the scene, the 112 ambulance staff pick up the injured driver and medical intervention is initiated.

The injured man has a severe stomach ache that he can feel in his back. He describes the pain as intermittent, surrounding his waist like a belt. Apart from some small scratches on his face, there is no active bleeding. There is also no visible bleeding in the abdomen. A physical examination indicates that the patient's blood pressure is low (100/60 mmHg), his pulse is weak and his ECG is normal. After about 5 min, his blood pressure is measured again and seen to be even lower (80/50 mmHg). The patient's respiration is troubled. However, listening to lung sounds indicates that both lungs are equally participating in respiration. The patient asks to have the cervical collar removed because it affects his breathing. The ambulance physician making the evaluation, suspects that the patient might be experiencing intra-abdominal bleeding. Because blood loss is suspected, the patient must quickly be administered serum by venous access. The healthcare team starts to make preparations for the administration of the serum.

The patient, however, who has so far kept his silence and watched the procedures, not being very involved and in fact absorbed in his own pain, suddenly objects to the administration of the serum. The day this is taking place is within the Islamic holy month of Ramadan and the patient is fasting.2 The patient states that his fast will be broken and his religious practice disrupted in the event that the serum is administered. The ambulance staff member informs him that his condition is life-threatening and that the serum must be administered. The patient now takes a more vehement stand. ‘If I am to die, I want to die while I am fasting. Today is Friday and I have always wanted to die on such a holy day,’ he says. The ambulance team tries to make a quick assessment about whether this decision of the patient is a conscious one and whether the patient is aware of its possible consequences.

The ambulance physician has little time to decide what to do. The patient is rapidly losing blood. The blood loss must be urgently replaced with the serum. Yet the patient does not accept this.

The case

Analysing the matter from a religious perspective is outside the scope of this paper. It would be useful, however, to examine the religious assertions that the patient has made in refusing medical treatment.

The ultimate decisions about life and death are not simply medical decisions.3 The use of religious references in refusing medical treatment is not a phenomenon that has been newly encountered. There have been many instances of ethical and legal discussions related, for example, adherents of Jehovah's Witnesses.4 5 Living and wishing to shape their lives according to religious teachings are of course matters related to people's personal preferences and more important, constitute one of the foremost of human rights.6 Also, it is expected that physicians should respect a competent patient's right to accept or refuse treatment.7 Just as they plan their lives, individuals may wish to plan for their deaths or processes of death according to specific points of reference. What is important at this juncture is whether the teaching or philosophy used as a reference point has been in fact correctly perceived. The rightness or wrongness of applications arising from such perceptions, however, does not depend only on the teaching that has become the point of reference. More determining are the reasons set forth by the implementer of such doctrines. Just as physicians should aim to provide relevant information regarding the medical procedures prior to patients consenting to have those procedures, they should also assist patients to think more clearly and rationally.8

As a matter of fact, differences of implementation have caused the emergence of many different denominations in Islam. There are different school thoughts in Islam and discussions here, are made from Sunni, Hanafi perspective. It is also a fact that, because of the existence of different interpretations, an individual who accepts a particular religious teaching as a point of reference may find him/herself brought into a situation that is unacceptable according to that same religious teaching.

This is the type of situation that is being studied here. The injured person has a religious point of reference for the end of life, but due to his own interpretation, falls into a situation that is in fact not approved by that same religious point of reference. Within the framework of the religious teachings of Islam, the faith has anointed the human being as the most noble among creatures, attaching great importance to human life and insistently recommending medical treatment.9 Fasting in Islam constitutes conscious abstinence from eating, drinking and sexual intercourse, from dawn to sunset.2 According to many Islamic scholars, the fasting believer who must be administered a serum will suffer a break of his/her fast, but one that does not require atonement, only a kaza prayer of compensation.10 (Kaza in Islamic terminology means to allow postponement of a religious duty to another time in certain conditions.) This is because what is at issue here is a human life. There are many situations in which it is considered acceptable to break a fast, times at which facility is rendered to the practice of fasting. Also according to Islam, the treatment of the individual in the life to come is believed will be determined by his/her actions on earth. No connection is made with the time or place of his/her death.10 On the other hand, in the meaning of a hadith, there are two pleasures in fasting: breaking the fast and the convergence to Allah.11 The injured man could have taken reference the hadith himself. Moreover, Islamic teaching has developed various algorithms to deal with decision-making processes in medical emergencies.12 Islamic doctrine is based on a reverence for life and accepts that refusing to be treated is a serious sin13; Islam has certainly prohibited suicide. In the light of all of this, the conclusion that can be drawn in the religious context of this case is that the individual here is exaggerating the implications of the religious point of reference, jumping to conclusions that are not in fact sanctioned by the religion and which are only subjective interpretations.

As mentioned at the beginning, the purpose of this article is not to analyse the case from a religious point of view. What is being attempted above is to show the error in the behaviour of the individual, who is acting from the perspective of a particular religious standpoint, by offering reference to sources of knowledge accepted by the same religion. Again, what is important here is whether or not the belief guiding the individual in his behaviour can in fact be evaluated within the framework of individual autonomy. The question of whether a point of religious reference is being rightfully used or how it is being used is completely the subject of theological discussion. What is being reviewed here is the autonomy of a patient in making use of a reference to a religious doctrine, even though the relevant teaching has been misinterpreted.

In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible.14 Traditional medical ethics regards the wellbeing and interests of the patient as a primary value. In the present case, the patient has been carried to the ambulance and bleeding has been stopped. Verbal communication with the patient has been continuous to achieve the patient's psychological comfort. The injured person has been informed of what is happening, which medical procedures are to be performed, which hospital he will be transported to, and so on. It has been observed that these explanations have been understood by the patient, who has given verbal reactions and made comments in response. The ambulance team has made every effort to provide the patient with the best care that conditions in the ambulance permits.

Respect for autonomy

Respect for persons is widely regarded as the fundamental basis of any ethics involving human beings.15 The most effective method of achieving individual autonomy is through the practice of obtaining informed consent. Informed consent constitutes the acceptance of a patient of the diagnosis and treatment methods to which he/she will be subjected, along with their benefits and possible undesired results, based on the information received regarding other alternative methods and their structural and outcome-related characteristics. Medical procedures that are undertaken without the patient's consent have no ethical or legal foundation. It is obvious that no medical intervention can be forced upon an individual exhibiting mental competence and free will who opposes that intervention. The problem that appears in this context is more an issue of what is to be done in the event the patient has impaired consciousness or has lost his/her decision-making competence. Closest family members are usually considered the first choice as surrogates because it is assumed that they know the patient best and that they have the wishes and best interests of the patient as a top priority.16 But, this is not possible in this case.

In the present case, two elements—competence and consent—must be examined in order to make a decision about the patient's autonomy. The communication the health team achieved with the injured party may be a guide in this analysis. The ambulance staff made every effort to set up a line of effective communication with the injured individual. The patient responded to questions with rational and conscious answers as to how the accident happened, where he was coming from and where he was going, what his occupation was, and so on. He remembered how he was removed from the vehicle. The conclusion at which the emergency medical team arrived after all of this was that the patient was conscious and competent enough to be aware of the consequences of his actions.

The principle of autonomy, outside of the exceptions recognised by law, encompasses all medical situations, including emergencies, where informed consent is required.17 Consent implies the patient's acceptance of the medical procedure to be undertaken after having been provided with accurate, simple and comprehensible information about that procedure. The medico-legal contexts with regard to capacity to consent may vary in different countries but the capacity to consent remains an important ethical and legal aspect of patient care in all settings.18 In the present case, the patient gave his consent to many medical procedures. He permitted the medical staff to place and fix him on the gurney, measure his blood pressure, fit him with a neck brace, put dressing on the bleeding parts of his body and administer oxygen via nasal tubing. The sole objection of the injured individual where he did not consent to the procedure was towards the attempt to administer serum. The patient connected his refusal to consent with his own interpretation of religious practice. When he was reminded of the stance of religious laws in situations like this, the patient stated that he did not accept such an interpretation. At this point, it could be seen that the patient was able to consciously provide grounds for his objection. It should be noted also that there is no institution can be urgent consulted in such cases by telephone or otherwise in Turkey.

In the context of respect for autonomy, another matter concerning medical staff and patient relations that must be analysed is the fixing or immobilisation of a patient on a gurney. An ambulance is a vehicle that speeds through traffic. Fixing the patient onto the stretcher with a safety belt is a requirement geared to prevent the patient from being jostled from side to side as he/she lies on the stretcher inside the ambulance. How can there be a reference to autonomy when the patient is tied down to a stretcher in this way? Is it not possible to say that a person in that position, surrounded by uniformed personnel, in an environment which is foreign to him/her and in a situation to which he/she has not given consent, is in a sense only partially autonomous? Physically tying the patient to the gurney, although an action that is performed for the benefit of the patient is a procedure that restricts the patient's autonomy.

Medical decisions that physicians must make in the name of the patient should not be grounds for ignoring a patient's autonomy. However beneficial a medical decision may be for a patient, this decision must not be taken without respecting the patient's autonomy. There is a conflict between autonomy and beneficence for ambulance crew. Emergency cases where speedy medical decisions are crucial are generally regarded as situations where physicians and other healthcare providers, in their desire to benefit the patient, will frequently ignore the principle of respect for patient autonomy. Society's expectation from organisations that provide emergency medical care is a paternalistic approach where the emergency medical staff eases the pain of suffering persons, thus performing, in other words, an act of benevolence. There is always the preconceived belief that the person in need of the emergency healthcare will consent to the procedures. It is when the patient voices an objection that from that point on, autonomy and respect for autonomy comes to the fore as issues.

According to a study on this subject, while patients are less likely to reject a medical intervention, healthcare professionals adopt the view that patients have the right to refuse a procedure and express more respect towards a patient's autonomy than patients themselves.19 It is indeed seen that healthcare providers are more sensitive than patients themselves to the rights of patients to refuse medical treatment in Turkey. To the contrary, according to another study, doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians' decisions as much as is often recommended in the ethics literature.20 In the present case, it is seen that while continuing their medical intervention, the emergency staff did not ignore the patient's right to object to the procedures. Analysing the reasons for the objection was not among their duties. The job of the emergency staff in this case was to establish whether or not the patient was making a conscious decision. In other words, their task was to determine the level of the patient's competence and to provide him with accurate information. If physicians are to promote autonomy, if they are to respect patients as persons, if they are to help patients to choose and do what there is good reason to do, they should care more about the rationality of their patients' beliefs.8

In the case in question, the injured person has adopted a religious teaching as a point of reference for himself. Everyone has the right to expect respect for his/her moral and cultural values and religious and philosophical beliefs.6 From the perspective of ethical values, a human being has the right to make a decision concerning his own physical person. In this case, however, a problem has arisen because the religious teaching has been exaggerated or misinterpreted. The same religious teaching exhibits a paternalistic approach that closely resembles the approach adopted in the context of emergency medical care. Islamic tenets teach that life is sacred and can only be ended by the will of God (Allah) and any other kind of death wish or actual death is accepted as the grave sin of suicide.

Conclusion

What is important in solving the ethical conflicts encountered in medical applications is to find the path that provides the least sacrifice of values, or in other words, the path that most conserves and protects values. In the case at hand, the members of the emergency healthcare team have found themselves in a conflict between the principle of acting in the best interests of the patient and the moral obligation of respecting the patient's autonomy. A deeper analysis of the situation reveals that the conflict is exacerbated when the obligation of not harming the patient is also considered. The answer to the question ‘should an action (or lack of action) that risks the life of an injured person be attempted in the interest of exhibiting respect for the patient's autonomy?’ is crucial to the approach to this dilemma.

The emergency medical professionals in this case have chosen to act in accordance with the principle of protecting the patient's best interests as a priority. Continuing to examine the case from the perspective of the ethical dilemma presented here, the medical staff applied an intravenous cannula after obtaining the patient's consent. The cannula is a plastic device used for flexible venous access. Although the cannula was applied to the patient, no fluid was infused. Thus, the ambulance staff respected the decision and therefore the autonomy of the patient. Their objective in attaching the cannula was not to connect the serum when the patient lost consciousness but to be prepared to find an appropriate venous route should the injured person later change his mind about the administration of the serum. If this had not been done, finding an appropriate vein to infuse the serum would present a medical challenge as time passed and the patient then changed his mind about receiving the medication.

The injured party did not lose consciousness before reaching the hospital and was delivered to the hospital fully conscious. The case was one that presented a number of ethical issues for the emergency medical team. The difficulties were exacerbated because the entire event transpired within about 15 min. The ambulance team thus found itself in the position of having to make a series of medical decisions in the space of a short period of time and the case has been described here as an attempt to emphasise how important it is for ambulance staff to be knowledgeable and aware of ethical concepts and approaches. It is important to improve communication and decision-making skills in ethically and culturally problematic situations.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.