Remembering Your Right of Refusal

Sep 17, 2014

IPFW Associate Professor and medical ethicist Abraham Schwab.
Credit Courtesy / Abraham Schwab

Let’s say that your father, mother, grandmother, sister, or other family member is admitted to the hospital. Given their poor and slowly deteriorating health, this admission comes as no surprise. Your loved one makes it through the event and is now ready to be discharged from the hospital.

Where should they go?

The answer we all would like to give: the place that best fits their medical and personal needs.

Sometimes this will mean going home, just as they were. Other times, it will require home health care, assisted living, or admission to a nursing home. The best choice for each patient will depend on both their medical condition and their social circumstances. Two patients with similar medical conditions may receive different recommendations because one has a live-in relative while the other does not. Similarly, two patients who both have live-in relatives may receive different recommendations based on the complexity of care their different medical conditions require.

Last Thursday night I had the pleasure of talking with twenty health care practitioners at the Village at Pine Valley (a Lutheran Life Villages facility) through an event organized by the Division of Continuing Studies at IPFW.  One perspective shared by many of the attendees was this: too many patients and too many patients’ surrogates don’t know they have the right of refusal.

These patients and their surrogates don’t realize that these recommendations at discharge from the hospital are just that: recommendations. So long as the patients (or their surrogates) maintain decision-making capacity, they are not required to follow the advice. They have a right to refuse.

We generally expect physicians and other medical practitioners to base their recommendations on the medical features of the case, on what’s best, medically speaking, for this patient. And, in general, medical practitioners aim to do just that—to recommend what’s best for the patient.

But more and more, the business side of medicine threatens to encroach on these judgments. Hospitals, and by extension other health care institutions, are under increasing economic pressure to eliminate patient re-admissions within 30 days. And this pressure will only increase. 

Over the next several years, Medicare could reduce payments to hospitals by as much as three percent if too many patients are readmitted within 30 days. A significant pressure on its own, the effects are all the more poignant as medical practitioners are stretched thin to cover more patients in less time.

And so, medical practitioners will make recommendations that, quite reasonably, will be the least likely to cost them and their employers. They will do what any rational person or business would do and make recommendations that are more conservative, involving more care rather than less, because they will hope that this will keep patients from coming back within 30 days.

"The right to refuse isn't limited to questions of discharge planning: it covers all of medical care. Patients are entitled to refuse the beta-blocker, the blood test, the surgery, and the biopsy."

Traditionally, informed consent and the right of refusal served to include a patient’s personal values when medical practice was controversial or when the standard care would not work for this patient. And it can serve this very purpose at discharge, though it may make the most sense for medical practitioners to recommend conservative care or more care, which may not be best for this patient. And this patient has the right to refuse.

The right to refuse isn’t limited to questions of discharge planning: it covers all of medical care. Patients are entitled to refuse the beta-blocker, the blood test, the surgery, and the biopsy. But let me offer a suggestion for those moments of refusal: have courage and tell the medical practitioner you are refusing. There may be an additional option or accommodation or possibility that may then be considered. But these options can only be mentioned if the medical practitioner knows you plan to refuse.

Remember, all the recommendations that physicians and other medical practitioners make are just that: recommendations. Each patient and each patient’s surrogate should keep in mind the right of refusal. Because no matter how well intentioned physicians and other members of the health care team may be, they can never know it all. And as the business of medicine intensifies its pressure on the practice of medicine, the right to refuse may be that much more important for patients and their surrogates.

 

Abraham Schwab is an associate professor of philosophy and medical ethicist at IPFW.

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