Informed Refusal

Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment.[1][2] Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.[3]

For a refusal to be legally binding, three conditions: The individual first needs to be in possession of the relevant facts. And second, he or she needs to be an adult and lastly, the refusnik needs to have her or his reasoning faculties in decent shape, meaning such as not being intellectually disabled or mentally ill and without an impairment of judgment at the time of refusing.

Such impairments include, but are not limited to illness, intoxication, drunkenness, using drugs, insufficient sleep, and other health problems.[2]

In cases where an individual is considered unable to give informed refusal, another person (guardian) may be authorized to give consent or to refuse on their behalf.

This concept grew out of and is similar to that of informed consent, but much less commonly used and applied.

In the United States of America it is formally recognized in certain state laws (California, Nevada, Vermont,  Michigan & a few others) as well as in various court decisions.[2]

Case in Point

Let’s say a physician has made an assessment of a patient and finds a specific test, intervention, or treatment is medically necessary. The patient refuses to consent to this recommendation. The physician then needs to explain the risks of not following through with the recommendations to allow the patient to make an informed decision against the recommendation. While in the past documentation of refusal of treatment has not been important, the widespread use of managed care, cost containment processes, as well as increased patient autonomy have created a situation where documented “informed refusal” is viewed as becoming more important.[3]

When refusal of treatment may result in significant damage or death, the interaction needs to be documented to protect the care giver in a potential later litigation against the allegation that the recommendation was either not made or not understood.

On occasion, a patient will also refuse to sign the “informed refusal” document, in which case a witness would have to sign that the informed process and the refusal took place.[1]

The pregnant patient represents a specific dilemma in the field of informed refusal as her action may result in harm or death to the fetus. Ethicists disagree on how to handle this situation.[4]

“The principle of informed refusal poses a specific problem when it is invoked by a pregnant woman who, in spite of having accepted her pregnancy, refuses the diagnostic and/or therapeutic measures that would ensure the well‐being of her endangered fetus. Guidelines issued by professional bodies in the developed world are conflicting: either they allow autonomy and informed consent to be overruled to the benefit of the fetus, or they recommend the full respect of these principles. A number of medical ethicists advocate the overruling of alleged irrational or unreasonable refusal for the benefit of the fetus.. The present essay supports the view of fetal rights to health and to life based on the principle that an ‘accepted’ fetus is a ‘third person’. In developing countries, however, the implementation of the latter principle is likely to be in conflict with a ‘communitarian’ perception of the individual – in this case, the pregnant woman. Within the scope of the limitations to the right to autonomy of J.S. Mill’s ‘harm principle’, the South African Patients’ Charter makes provision for informed refusal. The fact that, in practice, it is not implemented illustrates the well‐known difficulty of applying Western bioethical principles in real life in the developing world” (Source)

Given major paradigmic differences between the holisic and the conventional model of medicine, an informed refusal could be seen as harmful for the fetus by the Conventional doctors and beneficial by the holistic doctors and-or the informed mother. For example, let’s say the conventional hospital staff decides that a drugged caesarian birth would be the best treatment for a baby delivery. Because natural births have been shown to be way less dangerous and more beneficial for both the baby and the Mom, the hospitalized mother could refuse the Ceasaring delivery and request a natural birth delivery in a warm bath tub squatting with organic herbal treatments to help expedite oxytocin and dilate her uterine wall, inter alia.

But the Mother’s caregiver would have to act quickly to inform the conventional doctors that this procedure can be safe and efficient and would be clinically superior to the drugged caesarian one. Then it would be the responsibility of the hospital to get a warm bath tub and herbs asap. Because not having the best standards of care could be seen as a serious liability in a Court of law.

The Happiness Medicine Institute’s Public Health Recommendation

Given the fact the American conventional medical treatments are anywhere from the first to the third major cause of premature death (Source) (which includes over 120,000 Americans dieing each year from the proper (indicated) prescription drug (Source)), it is of the H.M. Institute’s opinion that all public and private schools, elderly centers, courts and public buildings should post the dangers (risks) of all medical systems as well as the risks of not getting appropriately and holistically treated,  and that all patients have the legal right to refuse any and all medical treatments.

And where the evidence of harm is established by a preponderance of the evidence, the warning should inform the public that people have not only a right, but also a civic duty to refuse any and all treatments that are un-necessary and burdensome in terms of public & private costs as well as those treatments that come with complications and deleterious side effects that tend to be worse than the disease the patient is getting treated for.

 Text under construction

  1.  American Cancer Society. “Informed Consent”. Retrieved 2007-04-15.
  2. James M. Goodman (March 2007). “Protect yourself! Make a plan to obtain “informed refusal“. OBG Management. 19: 45–50.
  3.  ACOG, Committee on Professional Liability (2004). “Informed Refusal (2004)”. Obstetrics & Gynecology. 104: 1465–6. doi:10.1097/00006250-200412000-00048.
  4.  Louis-Jacques van Bogaert (2006). “Rights of and duties to non-consenting patients – Informed refusal in the developing world”. Developing World Bioethics. 6 (1): 13–22. :10.1111/j.1471-8847.2006.00132.x. 16436170.
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