Justified Limits on Refusing Intervention

Abstract

Justified Limits on Refusing Intervention Respect for the autonomy of the patient is a dominant ethical principle in the literature on biomedical ethics, particularly in the literature on of medical intervention by competent or apparently competent patients. There seems to be a near uniform consensus that of surgical management of a gangrenous toe, religiously based of blood products to manage shock, and of cesarean delivery to manage complete placenta previa should always be respected. This consensus rests on the underlying view that of medical intervention is simply an instance of the general negative right to be left alone, i.e., a negative right to noninterference in the autonomous management of the affairs of one's life when no else is being harmed. We challenge this assumption and argue that refusal of medical intervention, in cases where the individual is not refusing any longer to be a patient, is not simply refusal, but that is necessarily combined with an implicit demand for alternative medical management. That is, of medical intervention is a complex moral phenomenon because it involves both a negative right to noninterference and a positive right to alternative treatment. Because a positive right is involved, the issue of ethically justified limits on patients' of medical intervention must be addressed. We undertake that task in this paper, focusing on the example of well-documented, complete placenta previa. [1] Negative and Positive Rights Refusal of medical intervention is a negative right simpliciter when the of medical intervention takes the form of refusing any longer to be a patient. In such cases, to respect the patient's refusal, that individual's physician need only do nothing. Thus, when the competent patient, for example, discharges him- or herself from the hospital against medical advice, he or she is asserting the negative right to be left alone by his or her hospital physician. When a patient refuses medical intervention, but does not withdraw from the role of being a patient, matters are more complex. A hospitalized patient with gangrene of a toe who refuses amputation but wants the gangrene treated on a trial basis, is (a) refusing surgery and (b) demanding the only other available alternative, namely, medical management. A Jehovah's Witness who refuses blood products in a situation when volume expanders (which need not be constituted of blood products) may be therapeutic is demanding the expanders on the grounds of religious objection to receiving blood. A pregnant woman who in the intrapartum period refuses cesarean delivery for a well-documented, complete placenta previa in favor of vaginal delivery is exercising a negative right not to have surgery and a positive right to medical management of the only other alternative, vaginal delivery. Finally, a patient with terminal disease who refuses aggressive management of the disease process but wants aggressive management of pain and suffering while he or she is dying is also exercising a combination of negative and positive rights. A negative right is usually understood in ethics as a right of noninterference in decisionmaking and behavior. A negative right therefore generates duties on the part of others to leave the individual in question alone. [2] In law, the rights to privacy and to self-determination, both pertinent to medical decisionmaking by patients, are negative rights not to be subject to nonconsensual bodily invasion. By contrast, positive rights involve a claim on the resources of others to have some need, desire, or want met. Such rights obligate others to act in specified ways in response, as illustrated in the above examples. As a rule, positive rights are in all cases understood to be liable to limits by their very nature. [3] This feature of positive rights contrasts sharply with negative rights, for which the burden of proof is on others to establish limits (for example, on the basis of preventing serious harm to innocent others). …