Fayetteville State University Refusal of Treatment in An Ambulance Case Study

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    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
    Department of Deontology and
    History of Medicine, Cukurova
    University, Adana, Turkey
    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;
    Received 22 January 2010
    Revised 17 May 2010
    Accepted 13 June 2010
    Published Online First
    26 July 2010
    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?
    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.
    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
    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
    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
    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 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
    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
    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.
    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.
    Provenance and peer review Not commissioned; externally peer reviewed.
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