Thank you.
"Refusing treatment
Under English law, all adults have the right to refuse medical treatment, even if that treatment is required to save their life, as long as they have sufficient capacity (the ability to use and understand information to make a decision).
Under the Mental Capacity Act (2005), all adults are presumed to have sufficient capacity to decide on their own medical treatment, unless there is significant evidence to suggest otherwise. The evidence has to show that:
•a person’s mind or brain is impaired or disturbed
•the impairment or disturbance means the person is unable to make a decision at the current time
Examples of impairments or disturbances in the mind or brain include:
•brain damage caused by a severe head injury, stroke or dementia
•mental health conditions, such as psychosis (where a person is unable to tell the difference between reality and their imagination)
•any physical illness that causes delirium (illusions, disorientation or hallucinations)
If a person makes a decision about their treatment that most people would consider irrational, it does not constitute a lack of capacity if the person making the decision understands the reality of their situation.
For example, a person with life-threatening cancer may refuse a course of chemotherapy because they would rather not tolerate the treatment’s side effects for the sake of a slightly longer life. They understand the reality of their situation and the consequences of their actions, and have therefore made a perfectly rational decision.
However, a person with severe, psychotic depression who refuses treatment because they wrongly believe that they have no hope of recovering and are so worthless they deserve to die would be considered incapable of making a rational decision. This is because they do not understand the reality of their situation.
Read more about consent to treatment.
Advance decisions
If you know that your capacity to consent may be affected in the future – for example, because you may become unconscious – you can arrange a legally binding advance decision (previously known as an advance directive).
An advance decision clearly sets out the treatments and procedures that you do not consent to. This means that the healthcare professionals who treat you will be unable to carry out certain treatments and procedures that are against your wishes.
For an advance decision to be valid, you must be very specific about what treatments and procedures you do not want and under what circumstances. For example, if you want to refuse a certain treatment, even if it means your life is at risk, you must clearly state this.
As long as the advance decision is valid and applicable, the healthcare professionals treating you must follow it. In other words, it must cover exactly the condition you go on to develop and the treatment decision being debated.
There must be no doubt about your capacity at the time of drawing up the advance decision, and it must be clear that you have a good understanding of your condition and any treatment you are refusing. There must also be no suggestion that you were being coerced (or unreasonably influenced) by others when you made the decision.
If there is any doubt about the advance decision, the case can be referred to the Court of Protection, which is the legal body that oversees the Mental Capacity Act (2005)."
We are talking about people who are incapable of making that decision. People like I was at one point. You would have left me to die. Fortunately, you are wrong about the law, and wrong about ethics, so I’m still alive thanks to medical professionals who actually did their job.
What you continue to miss is that the issue isn’t whether one can make a decision, it’s whether one can make a rational decision. That someone has attempted suicide is strong evidence that they can’t. This is made clear in your cite when it talks about people being unable to tell what is or isn’t real - such as someone suffering from depression and having suicidal thoughts, falsely believing that they would be better off dead.
People who are incapable of making a decision are by definition lacking in capacity and hence treatable.
Many actively suicidal people DO have capacity.
Only those suicidal persons who are psychotic, severely depressed or brain damaged and so on on lack capacity. Those with mild depression, anxiety and other mental disorders who retain capacity are not treatable against their will.
Dale Creggan, the prisoner mentioned above who has been on hunger strike for some forty days insisting his mental condition warranted a move to a secure psychiatric facility rather than remaining in prison, has been moved to Ashworth Hospital.
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I don’t have a dog in this fight, per se, but I wanted to share a couple of anecdotes from my time as an EMT (which I have been for the last 7 1/2 years):
What you’re referring to is the notion of implied consent. The default for any rescue worker (cops, firefighters, first responders, EMTs and paramedics) is that, if the patient was able to make a determination regarding his care, that he would consent to life-saving procedures (or at least potentially life-saving). Unless, of course, there’s a DNR present. But that can be problematic for a few reasons:
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Generally, if we arrive at someone’s home (or a nursing facility), and the patient has not already died, we have to see the DNR order to act according to the patient’s wishes. If there is an order, but not handy, we usually have to call our medical director to get his permission. Otherwise, we have to work the patient.
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In Indiana (at least…I’m not sure if other states have implemented this), the standard DNR does NOT cover the trip to or from a facility. There’s something called an EMS DNR, which states that, if the patient crashes on the way to the hospital, no measures are taken. It’s the same as a regular DNR, but it’s specifically for the ambulance.
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Let’s take a diabetic as a hypothetical. I’m called to a residence where a patient is unconscious, and is a known diabetic who is irresponsible about taking his medication/glucose readings/etc. Once we get the patient awake (usually by oral glucose or, for severe cases, an IV or injection - administered by a paramedic), we’ll let him come around enough to converse with us. They are generally groggy when they come to. After conversing with them long enough to reasonably suspect that there are no other issues at play, we’ll ask them if they want to go to the hospital. Very few actually say that they do. If they are deemed in their right mind, and they refuse transport, we get them to sign a release saying that we offered to transport them, and they refused. I always try to get a family member to sign also, as a witness. If the patient is someone that we know well, from making several visits to their residence (there’s one guy I can think of, right off the top of my head, who knows us on a first-name basis), we’ll try to talk them into going anyway, even if a family member drives them. And I’ve told some of our regulars “hey…if I come back out here tonight for this same problem, or one related to it, I’m taking you to the hospital whether you like it or not.” They usually seem okay with this. There has been one occasion where they still refused to go. A call for a police officer to arrive on scene usually does the trick. I refuse to do it without them around, though, because there have been cases where someone was transported against their will to a hospital, and have filed lawsuits claiming that they were kidnapped. Err on the side of caution.
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A few years ago, we were called to a restaurant for a patient. An elderly man had died at the table, surrounded by his family. He went face-down into his mashed potatoes and gravy. When we arrived, we placed him on the stretcher, and started moving towards the door. As we started to lift the stretcher to get him into the ambulance, there was a thud as the stretcher locked into place. The patient sat up, looked at us, and said “what the hell are you all doing?” We told him what was going on, why we were called. He said, “this shit happens all the time. Let me off of this thing so I can finish my goddamn steak!” We were stumped. We called our medical director (who is a doctor at one of the local hospitals), and told him what the problem was. He asked if the patient was in his right mind. I mentioned that going back to dinner after coming back from the dead seems like there may be something misfiring in the ol’ grey matter. Doc told me to document the shit out of everything, and make sure that the patient signs a refusal.
My point (and I think that I had one in there somewhere) is that implied consent can be troublesome in its own right.
This may not have helped anyone shed any light on a new corner of this debate, except maybe to illustrate that even something that seems black-and-white has a lot of grey area involved.
How do you assess self harmers who do not appear mentally disordered but refuse consent for transfer to hospital or administration of antidotes or suturing? How does the ER treat these if the patient does arrive there?
I have a little experience in that field, Pjen. My mother was an undiagnosed bipolar for many years. When I was in the 7th grade, she attempted suicide for the first time. She’s attempted it three or four additional times since then. My (now ex-) wife was an unmedicated bipolar for the majority of her life, and of our relationship. She also has borderline personality disorder, the occasional psychotic episode, and was a drug addict for many years.
Having spent so many years (including formative ones) around people with psychological issues, I feel, has placed me in an advantageous position, career-wise. I grew up in those situations. I sometimes joke, “I wouldn’t know what to do if the women in my life were sane.”
At work, I’m sometimes called the “crazy whisperer.” If I have a patient like in the situation you mentioned above, I can usually talk them into letting us take them to the ER. Sometimes I ask for a minute alone, and everyone goes to one side of the room, leaving me and the patient alone. Usually, I get them to realize that their actions have people worried about them, and can kind of talk them into realizing that their behavior, while normal for them, is not quite okay for everyone.
If I can’t, and their actions could be harmful to them, I get the cops to help out. I’ve had to have patients cuffed to the stretcher. I’ve had to tie them down. The police are usually on-scene for a situation like that, and they won’t let us in until they secure the scene, and you might be surprised at what just the presence of a cop will do. It’s been my experience that most people will give in, just to shut everyone up.
En route, I’ll call the hospital and let them know what I’m bringing to them. They generally have a team waiting for us at the ER, in case the patient decides to become combative.
In the case of force-feeding prisoners, it seems to me like the debate so far can be boiled down to a few very basic disagreements. Mainly, does the right to bodily autonomy trump the state’s responsibility to provide for those under its care? Also, does death (except as ordered by the state) constitute an ‘escape’ or an evasion, a circumvention of the state’s lawfully-imposed sentence?
In the case of the mentally ill, I think Pjen’s position and Steophan’s represent a similarly simple, apparently irreconcilably dichotomy. Pjen and Steophan both agree that forcing medical treatment upon someone who refuses it is immoral assuming that person is capable of consent. Where they disagree is on whether self-harm or suicidal ideation/intent is necessarily indicative of mental disorder and therefore incapability of consent. Steophan holds that it is, Pjen (and the law in the UK) hold that it is not. I’m not sure there can really be a reconciliation of this disparity.
To use myself as an example, I have a history of self-harm and of suicidal ideation. They aren’t frequent, and medication to regulate these occasional impulses would be wildly unwarranted. Whenever I’ve done myself injury, it has been from a very calm, deliberate desire to have a scar to represent a notably terrible event. Most people would probably say that’s extreme and unhealthy, but I don’t see how it’s significantly different from getting a tattoo. When I’ve considered suicide, it’s been from a very calm, deliberate process of introspection at the end of which I’ve concluded that I’m tired and would simply rather not keep going. It’s not despair or mania, just a quiet choice to opt-out. In the end, I’ve (obviously!) decided to keep going a while longer, but I don’t see how my decisions are a) the product of psychosis or b) anyone else’s business.
I suspect that Pjen would see this as a simple expression of my personal autonomy, and Steophan would see this as the expression of a serious mental illness. One would have me committed and involuntarily treated, the other would probably be very sad, but respect my right to do with myself as I please.
Very well summarised. I would add that I would not just let someone die but advocate life and support the person- if on hunger strike placing food before them and encouraging them to eat and drink. But, as you say, if they have legal capacity and are not mentally disordered or mentally ill (three separate categories by the way) then there is a total bar to treating a parson against their will.