Refusal of treatment and hunger strike
Gonzalo Herranz
department of Bioethics, University of Navarra
outline de lección, Murcia, 1996
b. Lucid suicides who refuse to be treated (gastric lavage, dialysis).
c. Refusal of treatment to minors: exemption religious of child abuse regulations.
The ordinary relationship, of offer of treatment, followed by acceptance and compliance, also includes disobedience and mild forms of refusal.
The very frequent omissions of the established guideline .
data Chilling: 40% of the prescribed medications are omitted. About 30% of proposed invasive interventions. 20% to 30% of the assigned check-up visits. Lifestyle indications are ordinarily neglected.
The patient tends spontaneously to be disobedient. A scale of personalities: from very strict obedient to frivolous rebels. A special subject of annoying patient is the non-compliant one. In medicine, obedience, compliance, is subject pending.
It is often not a formal refusal, but a dose adjustment, an adaptation staff of the treatment, the benefit/discomfort judgment made by the patient. To a certain extent, informed consent can be thought of as being given in two phases: at meeting staff doctor/patient when prescribing. And then, when the patient selects and modulates treatments. This is particularly true in the treatment of chronic conditions, in long-term psychiatric treatments deadline. A fascinating topic , in which rationality, simulation and the secret desire not to get better are at play.
But at other times, for deeper reasons, there is a refusal of life-saving treatment, treatment that puts the physician's professional sincerity at stake.
It should not be forgotten that the patient has the right to receive information about treatment alternatives and has the right to choose. Therefore, the patient can choose: he/she can accept one treatment or another, he/she can apply for a second opinion. He can even decide not to be treated: for fear of an intervention, for the cost of treatment, for a variety of reasons.
All of this can be negotiated: cognitive moment, negotiation, decision (to gather from article of Valencia the essentials of the doctor/patient relationship).
What raises problems in medical ethics are more specific types of refusal of treatment: of intervention necessary to save life, of treatments proscribed by religion itself.
The best known cases are those arising from religious or political convictions.
Some, fully rational, are based on respect for life, as in the case of the pregnant woman who does not want to follow the doctor's opinion that abortion can improve her prognosis.
Others are based on superstitions, on counter-rational convictions or on aberrant, fundamentalist interpretations of the Bible. This is the case of Jehovah's Witnesses in their refusal to receive blood transfusions, or of the followers of the Christian Science sect who refuse medical treatment, confident in the healing value of prayer.
Others correspond to cases of political dissidence, such as activists or prisoners on hunger strike.
rule basic ethics: In considering the legality and ethical propriety of medical or surgical treatment of a patient who, for whatever transient or permanent reason, lacks the capacity to consent to treatment, it is axiomatic that treatment that is necessary to preserve the patient's life, health, and well-being can be legally and ethically administered without consent. BMJ 1992;305:478-479.
The situations are well known, as they are usually reported in the media.
A disease that consists of refusing treatment:
b. Lucid suicides who refuse to be treated (gastric lavage, dialysis).
c. Refusal of treatment to minors: exemption religious of child abuse regulations.
American Academy of Pediatrics. Committee on Bioethics. Religious Exemptions from Child Abuse Statutes. Pediatrics 1988;81:169-171.
Cases. Children 3 or 4 years old, with meningitis, leukemia, pneumonia, intestinal obstruction, infections and tumors. For pseudo-religious reasons: Assembly of faith, christian Science, Assembly of Christ.
Role of religion in the Education and family and social life.
Freedom of parents to educate their children in their faith. But the limit of possible abuses is fuzzy.
Parents, whatever their religion, seek the welfare and health of their children.
Social tradition that takes into account age and maturity to establish dependence, the validity of mandates, the use of physical force and moral coercion.
But it is aberrant conviction, it is pseudo-religious, if it harms. Religious freedom is no defense for cruel or inhuman actions.
There is also distrust in doctors, little faith in medicine. People believe in faith healing: many diseases are cured without going to the doctor.
But, in the face of serious illness for which there are effective interventions, it is irrational to refuse treatment. You cannot risk death or permanent injury when effective interventions are available.
On the other hand, child mistreatment, abuse and abuse. Obligation to defend the weak, with persuasion and Education. Obligation to denounce abuses: derogation of secrecy.
The physician in a conflict of duties: importance of the family and the role of the parents vs. benefiting the child with medicine. They cannot passively contemplate making the child a martyr to the parents' convictions. They cannot deny the child basic and effective treatments.
Most court rulings are in favor of saving the child. Depending on the place, they take the child under the power of the court and give it to the doctor to be cured. Minnesota, 1992, case of a diabetic girl, in which insulin and the doctor were refused, the parents were not convicted. Influential in politics.
And what happens when the child, now grown up, capable of many decisions, of ethical consent, takes the side of his parents and plays the role of an adult who refuses treatment out of conviction.
You do not need to be of legal age, it is sufficient that you are a mature adolescent.
This leads us to study the case of the
Rule of the principle of autonomy. American judicial and cultural tradition, which has spread to Europe. Much more in academic, political and judicial environments than in the lives of individuals.
Anecdotes, from Ghandi to antinuclear.
Harsh episodes of political tension in the UK at Maze Prison, near Belfast, where 10 IRA activists died on hunger strike in 1981.
Episodes of social activism: suffragettes 80 years ago, antinuclear activists today.
Ordinary prisoners protesting prison conditions, errors in judgment.
status The Spanish government's special case for the event of the Grapos of Zaragoza, with the tragic death of Dr. Ramón Muñoz Fernández on March 27, 1990. There is an important ruling of the Constitutional Court that makes prevail, in the case of prisoners, by virtue of the special dependence they have on the State, the preservation of the right to life over the right to autonomous freedom from death by starvation, and which obliges the forced re-feeding of the striker.
But we have become accustomed to the civilized hunger strike, as in the case of the 0.7% activists.
A special case of the doctors in Pakistan, who are not on medical strike, but on hunger strike.
Medical ethics divided.
European-continental vision: FIGE.
Anglo-Saxon vision USA, UK, Portugal.
Reflection in WMA doctrine:
Declaration of Tokyo, 1975.
Declaration of Malta, 1991; revised in Marbella, 1992.
Significant change.
Tokyo. Guidelines for physicians regarding torture and other cruel, inhuman or degrading treatment or punishment of detained or imprisoned persons.
A prisoner who refuses food and whom the physician considers capable of rationally and sanely understanding the consequences of such voluntary refusal of food shall not be artificially fed. The physician's opinion as to the rational capacity of the prisoner shall be confirmed by at least one other physician not involved in the case. The physician shall explain to the prisoner the consequences of his refusal of food.
Malta/Marbella: On hunger strikers.
A long statement, which deals in its introduction with the conflict of values presented to the physician: the obligation to respect the sacredness of life, and the duty to respect the autonomy of the patient. A conflict that is aggravated in the hunger striker who has left clear instructions not to be re-fed when he goes into coma. Physician's dilemma.
The relationship is a physician/patient relationship. "This relationship can exist despite the patient's withholding consent to certain forms of treatment or intervention."
The final decision on the intervention should be left to the individual physician, without the involvement of third parties whose primary interest may not be the patient's benefit. However, the physician should make it clear to the patient whether or not he/she can accept the patient's decision to refuse treatment, or in case of coma, to refuse artificial feeding, which implies an immediate risk of death. If the physician cannot accept the patient's decision to refuse such treatment financial aid, then the patient should have the right to be seen by another physician.
Ethical conduct:
Do not exert undue pressure on the patient to stop the hunger strike.
Treatment or care for the hunger striker should not be conditioned on the hunger striker's suspension.
Duty to inform about consequences and specific hazards. Clarity of information. Use of interpreter.
Right to request a second opinion by the striker. The right to change physicians.
Treat infections and water balance. Any treatment applied must be consented by the patient.
Make sure the physician each day that the striker does or does not wish to continue his or her action. Desires for intercurrent treatment.
Keeping a medical record. Keeping of confidentiality.
When entering into confusion or coma, the physician must be free to decide for his patient the treatment he considers best for his condition, taking into account the decision taken during the patient's previous care, during the hunger strike, an independent and conscientious decision.
Defend the freedom of each striker in cases of collective strike, separating one from the other.
Duty to inform the family, if not prohibited by the patient.
Complex issue.
Commentary to the Code.
General distinction between adults and minors. Uncertain limit.
Discern the patient's Degree adherence to his "creed": talk to him alone, clarify his decision, without coercion from co-religionists.
Respect to the limit.
Promise honesty, and state what the physician's conduct will be.
To leave freedom.
Diversity of situations: scheduled surgery/emergency situations due to acute anemia.
Search for solutions: hemodilution, erythropoietin, recovery of blood from the operative field.