Paragraph 1: Provide a brief summary of the article.
Paragraph 2:
Identify and describe major ethical dilemmas that appear in the article-including who is affected by the issue and how.
Paragraph 3:
Paragraph 4:
Is the reading relatively clear or unclear, deep or superficial, strong or weak, insightful and complex or simple and biased?
Clinical ethics
A case study from the perspective of medical ethics:
refusal of treatment in an ambulance
Hasan Erbay,1 Sultan Alan,2 Selim Kadıoglu1
1
Department of Deontology and
History of Medicine, Cukurova
University, Adana, Turkey
2
Cukurova University Adana
Health High School, Department
of Midwifery, Adana, Turkey
Correspondence to
Dr Hasan Erbay, Cukurova
University, Department of
Deontology and History of
Medicine Balcali Kampusu
01330 Yuregir, Adana, Turkey;
hasanerbay@yahoo.com
Received 22 January 2010
Revised 17 May 2010
Accepted 13 June 2010
Published Online First
26 July 2010
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?
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.
652
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
J Med Ethics 2010;36:652e655. doi:10.1136/jme.2010.035600
Clinical ethics
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
J Med Ethics 2010;36:652e655. doi:10.1136/jme.2010.035600
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 elementsdcompetence and
consentdmust 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
653
Clinical ethics
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
654
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
J Med Ethics 2010;36:652e655. doi:10.1136/jme.2010.035600
Clinical ethics
knowledgeable and aware of ethical concepts and approaches. It
is important to improve communication and decision-making
skills in ethically and culturally problematic situations.
Competing interests None.
8.
9.
10.
Provenance and peer review Not commissioned; externally peer reviewed.
11.
12.
REFERENCES
13.
14.
1.
2.
3.
4.
5.
6.
7.
Case Records Journal of the Emergency and Disaster Health Services
Directorate. No: 16695. Kahramanmaras‚, 2008.
Qur’an 2:183e7, Sura Al-Baqara.
Brazier M. Medicine, patients and the law. Harmondsworth: Penguin Books,
1987:30.
Woolley S. Jehovah’s Witnesses in the emergency department: what are their
rights? Emerg Med J 2005;22:869e71.
Wreen MJ. Autonomy, religious values, and refusal of lifesaving medical treatment.
J Med Ethics 1991;17:124e30.
Universal Declaration of Human Rights, Article 18. United Nations General Assembly
Decision No:217 A(III). 10:1948.
Malta Declaration on Hunger Strikers, World Medical Assembly, 43rd World Medical
Congress. http://www.wma.net/en/30publications/10policies/c8/index.html
(accessed 17 Apr 2010).
J Med Ethics 2010;36:652e655. doi:10.1136/jme.2010.035600
15.
16.
17.
18.
19.
20.
Savulescu J, Momeyer RW. Should informed consent be based on rational beliefs?
J Med Ethics 1997;23:282e8.
Sunan al-Tirmidhi, v2, Hadith number: 2038.
_
ISAM.
Islamic rules. Istanbul: Publication of the Foundation for Religious Affairs,
1999.
Sahih-i Buhari, Savm, 9.
Albar MA. Seeking remedy, abstaining from therapy and resuscitation: an Islamic
perspective. Saudi J Kidney Dis Transplant 2007;18:629e37.
Qur’an 4:29, Sura An-Nisa.
Pellegrino ED. Toward a reconstruction of medical morality. Am J Bioeth
2006;6:65e71.
Harris J. Consent and end of life decisions. J Med Ethics 2003;29:10e15.
Benner P. Avoiding ethical emergencies. Am J Crit Care 2003;12:71e2.
Hartman KM, Liang BA. Exceptions to informed consent in emergency medicine.
Hospital Physician 1999;35:53e9.
Fassassi S, Bianchi Y, Stiefel F, et al. Assessment of the capacity to consent to
treatment in patients admitted to acute medical wards. BMC Med Ethics
2009;10:15.
Alan S, Uzel _I. Predisposition for respecting autonomy and paternalism of those
receiving and providing care at the teaching hospitals in Adana, unpublished
doctorate thesis. Adana: Çukurova University, Institute of Health Sciences,
Department of Deontology and Medical History, 2005.
Lawrence RE, Curlin FA. Autonomy, religion and clinical decisions: findings from
a national physician survey. J Med Ethics 2009;35:214e18.
655
Copyright of Journal of Medical Ethics is the property of BMJ Publishing Group and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written
permission. However, users may print, download, or email articles for individual use.
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
Read moreYour email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.
Read moreBy sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.
Read more