Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a patient should be allowed to refuse antibiotics and instead try to pray pneumonia away.
Should the doctors try to get a court order to treat Mina over her vocal objections?
Yes: 29%
No: 71%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Before patients are granted the autonomy to make their own medical decisions, they must meet certain basic cognitive standards, referred to as "having capacity."
Multiple tests for capacity exist, but the best-known test was described by psychiatric ethicist Paul Appelbaum, MD, and psychologist Thomas Grisso, PhD, in a seminal . Appelbaum and Grisso asked that patients communicate a consistent choice, understand information relevant to their medical condition, appreciate the consequences of various proposed interventions, and be able to manipulate information rationally.
Christian Scientists generally do not meet these standards. While they accept treatment for injury, they usually reject medication for illness because they believe that prayer may cure illness and modern pharmaceuticals will not. In short, they doubt the efficacy of medicine. (This contrasts with Jehovah's Witnesses, for example, who reject blood transfusions; though they acknowledge the efficacy of such transfusions, they view them as banned by the Bible.)
While prayer may or may not help patients in distress, a question for which there is considerable disagreement, antibiotics do cure bacterial pneumonia. Although Christian Scientists refuse to accept these medical "truths," they are permitted to make their own medical decisions -- an exception to Appelbaum's and Grisso's principles. However, they may not make similar decisions for their children.
If Mina had been a Christian Scientist for her entire life, the consensus among medical ethicists would be to allow her to refuse care under these circumstances. Complicating the situation is her recent conversion.
Edward Beiser, PhD, of Brown University, often described the challenge in such cases as "the Jell-O test." During childhood, almost all of us watched our parents or grandparents make Jell-O: first, pouring colored powder into a pan of boiling water and then refrigerating it until it cools about an hour later. The more impatient among us likely opened the refrigerator halfway through the process, probably several times, trying to determine at which precise moment the colored water gelled into Jell-O.
Similarly, bioethicists must ask how long, loud, and consistent a patient's change of heart must be before her new beliefs can govern her medical decisions. Is 1 month as a Christian Scientist long enough? Three days? Half an hour? As the stakes rise -- and especially in matters of life and death -- hospitals and physicians often ask for longer, stronger periods of consistency.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
Check out some of our past Ethics Consult cases:
Perform Involuntary C-Section on Model?