Page last updated at 04:20 GMT, Wednesday, 22 July 2009 05:20 UK

Can doctors just say no?

Dr James Armstrong
VIEWPOINT
Dr James Armstrong
Medical Defence Union

Doctor assessing patient
Patients sometimes request specific treatments

In days gone by, there was a perception that doctors knew best and had the final say - but things have changed and patients are increasingly instrumental in decisions about their care.

However, Dr James Armstrong, a medico-legal advisor for the MDU, says doctors sometimes still have to say no.

A patient's right to consent to or refuse treatment is widely accepted.


However, patients may not recognise that there are some circumstances when their doctors may feel obliged to say no to a request for treatment..

Clear communication and honesty are central to the doctor-patient relationship.

While all doctors have an ethical obligation to listen to their patients, they are not obliged to provide treatment that they believe is not clinically appropriate.

They may suggest alternatives to the treatment the patient is seeking or, if the patient insists on a particular treatment but the doctor cannot justify it clinically, it is open to the patient to seek a second opinion.

This is not an example of a "doctor knows best" approach to medicine; rather that doctors' duty of care requires them to weigh up the potential benefits of any treatment against the risk of failure or even possible harm to the patient.

'Last-resort'

In some cases, patients may request surgery which they are convinced will help them overcome a debilitating or upsetting problem.

It sometimes proves impossible to achieve a meeting of minds
For instance, a woman in her thirties with heavy periods who believes that a hysterectomy represents her best option for a normal life or a teenager who requests a tonsillectomy to avoid further absences from school with tonsillitis.

Obviously, every patient is different but in general, many doctors would consider a hysterectomy as a last-resort for a patient of child-bearing age.

Removing a patient's tonsils, meanwhile, is not guaranteed to prevent throat infections and as with all surgery, it carries an element of risk and it is up to these doctors to weigh up all the considerations and to advise the patients accordingly.

The General Medical Council's guidance says doctors should discuss treatment requests from patients - but that if they don't feel it is of "overall benefit", the medic does not have to provide the treatment.

'Last chance'

However, the doctor should also tell the patient of his or her right to a second opinion from another doctor.

Occasionally, particularly where the patient is either too young or otherwise lacks the capacity to express their own wishes, a member of their family may request particular treatment for their relative.

Such cases can be particularly emotive because the patient may be extremely unwell and the treatment requested may be seen as a last chance to save them or prolong their life.

Sometimes when an agreement about the patient's best interests cannot be reached, the only way forward is to ask a court's opinion, as in the recent high-profile case of Baby OT, a seriously ill baby boy with a rare metabolic disorder.

The doctors looking after Baby OT felt that he was suffering intolerable pain and had no prospect of recovery and that treatment was no longer in his best interests - but his parents strongly disagreed.

With no prospect of agreement, the hospital asked the High Court to decide whether it would be lawful to withdraw life-sustaining treatment.

After a nine-day hearing, the High Court judge agreed that to continue treating the child would not be in his best interests and that the doctors could therefore lawfully switch off the ventilator.

The parents were refused leave to appeal and Baby OT died shortly afterwards.

In our experience, it is possible to have an open, informed and productive discussion about treatment options which can even strengthen the doctor-patient relationship.

However sadly, it sometimes proves impossible to achieve a meeting of minds.



Should doctors always be able to have the final say - or do patients deserve to have more input into how they are cared for?

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