Respecting Patient Autonomy

In medical ethics, a challenging situation that many physicians face is respecting patient autonomy rather than providing treatment that could potentially be life-saving, asserting that every individual holds the right and autonomy to make decisions and determine the course of their own medical care. This principle of respecting patient autonomy rather than providing treatment is salient in cases where the patient refuses care based on their deeply held religious beliefs. However, in some situations such as in the case of Dr. Sullivan, complexities arise when a patient refuses to receive care based on their religious beliefs despite the need for urgent medical intervention. Building on this case, the paper argues that a physician should always respect patient autonomy even when the physician disagrees with the patient’s beliefs and values regarding medical interventions. I will discuss the supporting evidence for the violation of the patient’s autonomy and the underlying reasons that led up to this incident on an evening in Cook County. The paper also includes the individuals who, in my opinion, should be held responsible and which parts of the professional code of ethics were violated.

Jukka Verelius (2006) in “The Value of Autonomy in Medical Ethics” emphasizes that patient autonomy is the fundamental ethical principle in medical care which upholds that every person retains the right to make their medical decisions on their own behalf, encompassing the freedom to decline any proposed treatment option.^[1] On one hand, medical professionals have a responsibility to provide benefits to a patient and promote a patient’s overall well-being even if those interests are influenced by religious beliefs. Central to the principle of honoring patient autonomy is the concept of informed consent. James Stacey Taylor (2004) in the work “Autonomy and informed consent: a much misunderstood relationship” argues that informed consent has a vital role in patient autonomy because it provides the patient with information and ensures that the information is sufficiently understood. For the consent to be valid, it must be voluntary and informed as well as given voluntarily by a capable patient who cannot be pressured or persuaded by family, health professionals, or others. The individual must have been adequately informed about the benefits, potential risks, and available alternatives of the proposed treatment^[2]. From a medical perspective, transfusing blood might be the most effective course of treatment to save Sullivan’s patient’s life but respecting her autonomy means acknowledging her autonomous integrity to make basic decisions about her own body and medical treatment, even if she refused treatment based on her religious faith. This paper discusses how physicians can effectively treat patients while respecting patient autonomy and certain situations that require interventions while giving precedence to autonomy over all else.

Considering the scenario where a woman was diagnosed with a life-threatening condition that required urgent medical intervention such as a blood transfusion to save her life when she was brought to the emergency department with critically low blood pressure. However, she was a devout adherent of a religious belief that prohibits certain medical treatments including blood transfusions so she adamantly refused on religious grounds. The physician Dan Sullivan explained the potential life-threatening outcome if she did not receive the blood transfusion “I told her there was a very high likelihood she would die without blood, and again she refused.”^[3] The patient stated that she understood the possible life-threatening outcome and she repeated back the informed consent statement. Shortly after, the patient lost consciousness and her blood pressure continued to plummet. Doctor Sullivan inquired with his colleagues on what action he should take but they were also uncertain “I asked my physician colleagues what they thought, and they had no idea” after which Dr. Sullivan was recommended by the hospital administrator to “call the hospital attorney, who was not available after hours” and then the administrator “began calling for a judge on call” in their “jurisdiction” but they “ran out of time” as woman’s condition kept on deteriorating.^[4] When Dr. Sullivan realized that the patient’s death was imminent as her health deteriorated further with the clock ticking every moment, Sullivan decided to transfuse the blood. Sullivan also called the “GI specialist and surgeon” as he requested gastrointestinal surgery to cease the internal bleeding after the patient had “4 units of blood” and woke up within 2 hours.

When the patient learned she had been treated with another person’s blood she not only was in rage but also threatened to sue Sullivan and the other healthcare team members that were involved leading the case to a deeply complex and ethically challenging situation. In cases like Sullivan’s administration of blood transfusions without the patient’s consent as her condition posed a significant risk to her health, there are limits to respecting patient autonomy and healthcare professionals might face a moral obligation to intervene, even if it means overriding the patient’s wishes. Although Judge agreed with Sullivan’s decision, once he returned the call, based on the fact that the woman experienced a loss of consciousness and was not capable of making her own medical decisions for her life, patient autonomy was compromised as Sullivan could found a solution that respected both her religious convictions and her medical needs to demonstrate a commitment to patient-centered care and uphold the principles of autonomy. In this case, the patient was initially competent and refused blood transfusions based on her religious beliefs as the patient was a Jehovah’s Witness, one of the individuals who do not accept blood products from other individuals for religious reasons. However, once she became unconscious, the situation became more complicated and the weight heavily fell on the treating physician to proceed with the transfusions, prioritizing the preservation of her life but that woman’s prior explicit refusal should be honored. Sullivan could seek guidance from an ethics committee or legal counsel but in the heat of the moment, these resources were not available and readily accessible so he used his best judgment to prioritize the well-being of patients based on their best interests.

Although Sullivan was primarily responsible for treating the patient against that patient’s religious beliefs, the hospital administrator also contributed to the decision-making. As a hospital administrator, it is their professional responsibility to oversee operations within a hospital setting as well as ensure that the facility complies with all laws and regulations.^[5] Healthcare professionals must follow the principle of treating patients according to their preferences and must not perform any interventions against patient’s wishes.^[6] In accordance with the first principle of the “National Association for Healthcare Quality” (NAHQ) code of ethics, “Healthcare quality professionals understand that recipients of healthcare services are the most vulnerable stakeholders in the system. They treat recipients with empathy and respect, honoring their autonomy and privacy” (NAHQ 2024).^[7] In the present case, Dan Sullivan did not meet his professional standards as he violated patient autonomy disrespecting the woman’s privacy rather than honoring it.

Furthermore, according to the National Library of Medicine, “The philosophical underpinning for autonomy, as interpreted by philosophers Immanuel Kant and John Stuart Mill, and accepted as an ethical principle, is that all persons have intrinsic and unconditional worth, and therefore, should have the power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination.”^[8] Building on the National Library of Medicine’s argument, utilitarianism, as defined by Mill is a consequentialist ethical theory that evaluates actions based on their outcomes in promoting happiness or reducing suffering. While applying to Dan Sullivan’s case, utilitarianism emphasizes the importance of patient autonomy as independently valuable. According to Mills, the theory of utilitarianism is based on the idea that “actions are approved when they are such as to promote happiness, or pleasure, and disapproved of when they have a tendency to cause unhappiness, or pain.”^[9] Mill equates happiness with pleasure and the lack of pain or suffering. In this context, respecting a woman’s decision takes precedence over potentially saving her life through a blood transfusion, as it promotes her overall happiness and well-being. This theory shows that allowing patients to empower individuals to make informed decisions regarding medical interventions even in the case of life-threatening conditions, empowers them to have a voice in their healthcare which fosters a sense of respect and trust in the patient-physician relationship. Mill’s theory also shows that providing patients with detailed information about treatment options enables them to make decisions that align with their preferences and values, including considerations of religious beliefs and weighing the risks and benefits of different medical interventions.

On one hand, it may be argued that the physician fulfilled his responsibility and ethical duty by providing life-saving treatment to the patient as she might not have been in the right capacity to make decisions for herself and her medical care due to her religious faith. In accordance with the first principle in the AMA code of ethics, “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”^[10] Sullivan’s reaction not only disregarded the patient’s religious beliefs but also did not respect human dignity and rights. The term “human dignity”, as defined by Emmaline Soken-Huberty, is “the belief that all people hold a special value that’s tied solely to their humanity” (Human Rights Careers, 2020).^[11] When a physician respects human dignity they are also holding patient autonomy in high regard, however, in Dan Sullivan’s case study, it was the hospital administrator and fellow physicians’ responsibility to engage when Sullivan was administering transfusions and patient autonomy as well as self-determination were violated. However, it may also be argued that the patient had sufficient information to make an informed decision and condescending or paternalistic actions might violate her autonomy. On the other hand, the patient’s refusal of a life-saving treatment option, though it was against her religious faith, was irrational and compromised her judgement. However, it is important to recognize that respecting patient privacy and autonomy means respecting the patient’s autonomy to make informed decisions even if those decisions are perceived as irrational by others.

In conclusion, Dan Sullivan and the other healthcare team members involved were not charged with medical malpractice nor did Sullivan lose his license to practice after violating the patient autonomy. Patient autonomy is complex and in certain situations can be difficult to navigate but should be respected even when the patient’s decisions contradict the physicians’ decisions. Many factors play into why a person’s patient autonomy is violated including time pressure and personal biases, posing the broader ethical implications and potential consequences of care providers’ actions. Within the healthcare system, patients and the community place a significant amount of trust in the healthcare members. It is up to the medical team to work collectively to respect not only patients’ autonomy but also their values and morals while respecting patient’s values and beliefs.

Bibliography

“AMA Principles of Medical Ethics.” Accessed May 3, 2024. https://code-medical-ethics.ama-assn.org/principles.

Bhati, Deepak, Meena S. Deogade, and Deepika Kanyal. “Improving Patient Outcomes through Effective Hospital Administration: A Comprehensive Review.” Cureus 15, no. 10 (2023).

“Code of Ethics – NAHQ.” Accessed May 3, 2024. https://nahq.org/about-nahq/code-of-ethics/.

Driver, Julia. “The History of Utilitarianism.” In The Stanford Encyclopedia of Philosophy, edited by Edward N. Zalta and Uri Nodelman, Winter 2022. Metaphysics Research Lab, Stanford University, 2022. https://plato.stanford.edu/archives/win2022/entries/utilitarianism-history/.

Soken-Huberty, Emmaline. “What Is Human Dignity? Common Definitions. | Human Rights Careers.” Accessed May 3, 2024. https://www.humanrightscareers.com/issues/definitions-what-is-human-dignity/.

Sullivan, Dan. “CASE: Refusal of Care Based Upon Religious Beliefs.” Accessed May 3, 2024. https://blog.thesullivangroup.com/case-refusal-of-care-based-upon-religious-beliefs.

Taylor, James Stacey. “Autonomy and Informed Consent: A Much Misunderstood Relationship.” J. Value Inquiry 38 (2004): 383.

Varelius, Jukka. “The Value of Autonomy in Medical Ethics.” Medicine, Health Care and Philosophy 9 (2006): 377–88.

Varkey, Basil. “Principles of Clinical Ethics and Their Application to Practice.” Medical Principles and Practice 30, no. 1 (2020): 17–28.

1. Jukka Varelius, “The Value of Autonomy in Medical Ethics,” Medicine, Health Care and Philosophy 9 (2006): 377–88. ↑
2. James Stacey Taylor, “Autonomy and Informed Consent: A Much Misunderstood Relationship,” J. Value Inquiry 38 (2004): 383. ↑
3. Dan Sullivan, “CASE: Refusal of Care Based Upon Religious Beliefs,” accessed May 3, 2024, https://blog.thesullivangroup.com/case-refusal-of-care-based-upon-religious-beliefs. ↑
4. Sullivan. ↑
5. Deepak Bhati, Meena S. Deogade, and Deepika Kanyal, “Improving Patient Outcomes through Effective Hospital Administration: A Comprehensive Review,” Cureus 15, no. 10 (2023). ↑
6. Taylor, “Autonomy and Informed Consent: A Much Misunderstood Relationship.” ↑
7. “Code of Ethics – NAHQ,” accessed May 3, 2024, https://nahq.org/about-nahq/code-of-ethics/. ↑
8. Basil Varkey, “Principles of Clinical Ethics and Their Application to Practice,” Medical Principles and Practice 30, no. 1 (2020): 17–28. ↑
9. Julia Driver, “The History of Utilitarianism,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta and Uri Nodelman, Winter 2022 (Metaphysics Research Lab, Stanford University, 2022), https://plato.stanford.edu/archives/win2022/entries/utilitarianism-history/. ↑
10. “AMA Principles of Medical Ethics,” accessed May 3, 2024, https://code-medical-ethics.ama-assn.org/principles. ↑
11. “What Is Human Dignity? Common Definitions. | Human Rights Careers,” accessed May 3, 2024, https://www.humanrightscareers.com/issues/definitions-what-is-human-dignity/. ↑