If a woman is diagnosed breast cancer and decides not to undergo treatment, we would persuade her but would accept her final decision. This is respect of autonomy and is one of the cornerstones of modern medical ethics.
In January 2013, a premature baby was born at a hospital in Hong Kong. Because of a complication of brain infection, the doctors recommended surgery. The father refused. That night, the hospital applied for guardianship and performed the brain surgery against the family’s wish. In April, the team operated on the baby’s eye, again despite the father’s protest. Last month, the baby was finally stable enough to enjoy a weekend at home. This time, however, the father refused to bring his son back to the hospital. The hospital obtained another court order and took the baby back.
Was autonomy being violated in this case? The doctors would argue that the father was after all not the baby himself. In the consent process, healthcare professionals were not asking what the guardian wished but what the baby would want should he have the ability to choose. When the father’s decision did not appear to be in the best interest of the baby, the team overrode his choice based on beneficence (to do good).
This story drew my attention as our team was involved in the care of two old ladies with bile duct obstruction and infection recently. Both ladies were in their nineties and suffered from multiple illnesses. Without intervention, the infection could be lethal. On the other hand, to clear the obstruction, we had to perform endoscopy, which was also very risky given their background. In face of such dilemmas, we used the standard tactics – explain everything to the families and let them choose. Ironically, the family of the sicker lady, who even depended on mechanical ventilation at night, insisted on aggressive treatment. She underwent two endoscopic procedures. More is yet to come.
In difficult situations like this, letting family members make the decision is the safest approach if the primary aim is to avoid complaints. Come to think of it, however, seldom do we ask what the patient herself really wants.