Refusal to Permit Medical Treatment and the Power of Person-Centered Care
A 34-year-old G1P0 (gravida 1 para 0 – first pregnancy, no
prior deliveries) arrives at her local hospital at 41 weeks
gestation for routine antenatal testing. The patient is a recent
immigrant to the US from a remote African village. While she
speaks English as a second language, she does so fluently.
She comes in on the dayshift for a nonstress test (NST). She
has had an uneventful prenatal course and has no risk factors
other than being post-dates (overdue).
The NST is non-reactive so an ultrasound for
Biophysical Profile (BPP) is ordered. The resulting BPP score
is 4/10. This, combined with the fetal heartrate tracing,
indicates that the baby would not tolerate labor.
The obstetrician on call, busy with patients in the clinic,
asks the nurse to tell the patient that she needs a cesarean
section. The patient, having only ever seen a nurse practitioner
in the clinic, has never met this obstetrician or this nurse.
After discussion with the nurse, the patient refuses the cesarean
The obstetrician is called and told that the patient refuses
the cesarean section. He has not had lunch and has a repeat
cesarean birth scheduled at 12:30 p.m. for another patient, and
the clinic resumes promptly at 2:00 p.m. He has a very full
afternoon clinic schedule with patients double-booked. He enters
the patient’s room at 12:20 p.m. and has a brief conversation
with the patient regarding the risks of refusing a cesarean
section. The conversation goes badly and the patient is now in
tears, still refusing the cesarean section. The obstetrician
leaves the room, proceeds with his scheduled case, then returns
to the clinic.
Later during shift change, the oncoming evening shift nurse
is given report that the patient is refusing a cesarean section
that is likely life-saving for the baby. The evening nurse
assesses the patient and suspects that a lack of trust in the
provider is causing the patient to refuse care. The evening shift
nurse spends the next six hours establishing a therapeutic
relationship with the patient. The patient subsequently consents
to the cesarean section and gives birth to a healthy baby
It is easy to see the many places where things could have been
better: the provider was over-burdened, the dayshift nurse had to
discuss the need for major surgery without the benefit of the
obstetrician providing informed consent, and the patient had no
relationship with the obstetrician on call. One can sympathize
with the patient, and understand why she refused life-saving care
even though, given the harm that will come to the infant, the
refusal is hard to accept.
Fortunately, as the patient was not yet in labor, there was time
to make things right. The evening shift nurse had the benefit of
a fresh perspective. She could see how busy the unit had been on
the day shift, she knew that the obstetrician had been extremely
busy in the clinic, and she saw that her patient was terrified.
By placing the patient, her family, and her unborn son at the
center of the conversation and then actively listening to what
the patient had to say, the nurse was able to help the patient
work through her fear. This is the real power of the
person-centered care movement and every member of the care team
must realize that the key to saving a patient’s life may not be a
drug or a surgery. It may be as simple as placing the power of
choice directly in the patient’s hands and then listening to what
they have to say.
Principles of Health Care Ethics
Autonomy: Respect patients’ rights to make decisions about
Beneficence: Provide care that maximizes the benefit to
Non-maleficence: Protect patients from harm.
Justice: Provide equitable access to resources and respect
morally acceptable laws.
Most textbooks and articles written on the principles of ethics
in health care discuss autonomy, along with beneficence, justice
and non-maleficence. While sometimes considered to be
hierarchical and potentially in conflict with each other, these
four ethical principles should be more aptly described as
inextricably tied together. Many discussions of health care
ethics mention that failing to respect the autonomy of a
competent patient in the name of justice, beneficence or
non-maleficence may violate the very principles the clinician is
trying to uphold. For example, if a clinician chooses a
well-meaning, but paternalistic approach to care, he or she may
actually do harm to patients as justice, beneficence and
non-maleficence unmoderated by a respect for personal autonomy
are nether beneficial nor harmless.
In the case described above, it appeared to be impossible to
simultaneously honor autonomy for the mother
(refuse cesarean birth) and non-maleficence for the baby
(avoid labor). Apparent conflicts between these principles often
are reduced or eliminated if the care of the patient is
approached in a thoughtful manner. This may require that the
clinician put aside his or her personal beliefs and cultural
biases. Understanding the patient’s point of view and improving
the patient-provider relationship are important steps in this
The CHPSO database is an excellent source of case examples from
which valuable lessons may be learned about why patients refuse
medical treatment. While there may be little that can be done to
change the patient’s mind, particularly in the setting of
strongly held cultural or religious beliefs, clinicians’ actions
may unwittingly contribute to the patient’s refusal of medical
treatment. It is as simple as taking the time to connect with the
patient to truly understand his or her perspective.