ethical considerations of the patient who refuses cancer treatment

Patients have a well-defined right to refuse care based on the principle of autonomy and legally grounded in the due process clause of the 14th Amendment, as established in the 1990 Cruzan case. 2 The 2011 American Medical Association Code of Ethics states that physicians have an obligation to discuss benefits, risks, and costs of appropriate interventions, and patients then have the right to accept or refuse any recommended medical treatment. 3 If an informed patient refuses care and declines further follow-up, the oncologist's role is limited.

Full Answer

What are the ethical issues in cancer treatment?

PIP: Ethical issues in the treatment of cancer patients was the subject of a international conference on supportive care, sponsored by the World Health Organization. Communications deficiencies between patients and doctors cause anguish and create a situation for ethical conflicts and dilemmas.

How should cancer care be responsive to patients'wishes?

One of the principles of modern cancer care is that it should be responsive to the patients' wishes and consistent with their values. 1 This is why it is important to understand how patients arrive at treatment decisions.

Do patients have a right to refuse medical treatment?

Competent patients have a right to refuse treatment. This concept is supported not only by the ethical principle of autonomy but also by U.S. statutes, regulations and case law. Competent adults can refuse care even if the care would likely save or prolong the patient’s life.

Is it possible to refuse chemotherapy?

Refusing chemotherapy is not a common reaction on the part of cancer patients. The majority readily accept primary treatment recommendations. 5 If the choice were totally theirs, most cancer patients would be likely to opt for chemotherapy, even if there were only a small chance of improvement.

What are the ethical and legal considerations involved in refusing patient service?

Both the ethical opinions and legal precedents agree that a physician may not intentionally and unilaterally sever an existing relationship with any patient, unless the physician provides reasonable notice to the patient, in writing, and sufficient time to locate another physician.

What do you do if someone refuses treatment for cancer?

If you feel your loved one is refusing treatment because of denial, or because of fear of undergoing treatment, talk to the oncologist. You may want to visit a counselor or support group together.

What are some of the ethical concerns related to cancer patients and their care?

These issues often concern oncologists in their day-to-day practice.Diagnosis and detection of cancer. ... Extent of patient information. ... Inclusion in clinical trials for novel therapies. ... Planning treatment. ... Alternative treatments. ... Withdrawal from active treatment. ... End of life issues. ... Other ethical issues.More items...

Why is refusal of treatment an ethical dilemma?

In general, ethical tension exists when a physician's obligation to promote a patient's best interests competes with the physician's obligation to respect the patient's autonomy. “When you don't take your medication, you're more likely to get sick.”

Are you allowed to refuse cancer treatment?

Treatment decision making is an ongoing process; thus, patients who initially refuse treatment may later choose to undergo conventional cancer treatment if given the adequate support, information, and time necessary to make the decision.

What should a nurse do when a patient refuses treatment?

If your patient refuses treatment or medication, your first responsibility is to make sure that he's been informed about the possible consequences of his decision in terms he can understand. If he doesn't speak or understand English well, arrange for a translator.

What are examples of ethical considerations?

Ethical considerationsInformed consent.Voluntary participation.Do no harm.Confidentiality.Anonymity.Only assess relevant components.

What are the ethical principles?

The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice, are defined and explained.

What are the ethical implications of breast cancer?

Numerous ethical issues applicable to breast cancer (and to other chronic and/or cancer diagnoses) include: informed consent; education of relatives, friends, and public; patients' comfort in discussion of their diagnoses and treatment; access to care; and allocation of scarce resources.

What is the nurse's legal and ethical responsibilities toward the patient who refuses medical care or treatment?

All clients have the legal right to autonomy and self-determination to accept or reject all treatments and interventions. With the exception of emergencies, all aspects of nursing care and interventions must be explained to the patient.

What are the patient's rights to refuse treatment?

Every competent adult has the right to refuse unwanted medical treatment. This is part of the right of every individual to choose what will be done to their own body, and it applies even when refusing treatment means that the person may die.

What do you do when someone refuses medical treatment?

What to Do if Your Loved One Refuses to See a DoctorBe transparent and direct. ... Convince them that it's their idea. ... Make it a "double-checkup" ... Make the rest of the day as enjoyable as possible. ... Get someone who is an authority figure to help.

What is striking about the refusals of oncologists?

Oncologists. It is striking that none of the oncologists talked about the context or the personal values of the patients. The refusals were evaluated from a medical (alternative medicine included) or rather narrow psychological perspective (personality of the patient, anxieties, coping style).

How to understand treatment refusal?

To understand treatment refusal, it was necessary to get a grasp of the contextual aspects related to the decision. “Context” is a rather broad term. Here it denotes all the personal circumstances relevant to someone's decision. In daily life, decisions are influenced by various forms of knowledge, values, belief systems, or meanings of life. 15 The individual can be seen as a specific intersection of various webs of meaning embedded in his or her particular context. New data, such as the news about having cancer, are interpreted within the contextual framework of these webs. Each patient tries to understand the news within his own language and perspective on life. 16

What is a good reason for a treatment?

As one of them stated: “It implies having information on a certain problem, being well-informed about the advantages and disadvantages, and balancing the pros and cons against each other. If the pros are heavier than the cons, you should make that decision.”

What is informed refusal?

Contemporary informed refusal procedures require that physicians respect their patients' decision to forgo possibly life-sustaining chemotherapy if the patients have decision making capacity. 23 This legally stipulated form of respect does not mean the physician has to agree with the decision.

What are the disadvantages of chemotherapy?

The disadvantages of chemotherapy that she and the other patients referred to were: negative experiences with previous courses, expected side effects, perceived effects on others, uncertainty of the resulting effect on their health, and the idea that an adjuvant treatment makes no sense as long as they feel well.

How are decisions influenced in everyday life?

In daily life, decisions are influenced by various forms of knowledge, values, belief systems, or meanings of life. 15 The individual can be seen as a specific intersection of various webs of meaning embedded in his or her particular context.

Why is the response to AZVU so low?

Most patients were too ill to participate or had already died. A second reason for the low response might be the composition of the patient population of the AZVU. According to the oncologists, most of their patients are prepared to fight cancer and know that the AZVU provides them with the latest treatment options.

What is the obligation of an oncologist?

The oncologist has the obligation at the time of initial consultation to educate the patient regarding the prognosis, options, and potential consequences of declining therapy. Patients should be informed whether the decision to forgo a therapy will limit their future options.

What does it mean when a patient chooses alternative therapy?

In choosing to undergo alternative therapy, the patient is indicating that she remains concerned by the risk of recurrence and wishes to take action. She believes the herbal therapy is an acceptable alternative to surgery. The oncologist disagrees and feels that she is acting on misinformation.

What is shared decision making in cancer care?

In cancer care, we believe in a model of shared decision making. 1 This is particularly true in the management of early-stage breast cancer, which can involve difficult decisions regarding surgical approach and adjuvant therapy. Patient preferences weigh heavily in determining the ultimate course of care. Oncologists understand that a patient may decline therapy or a component of therapy regardless of the physician's recommendation. However, although there has been considerable attention in the literature to shared decision making, there has been relatively little attention to what happens when patients and physicians disagree. What are the oncologist's obligations in the ongoing care of that patient?

What is the role of an oncologist in alternative care?

The oncologist is asked to use his or her medical authority to order laboratory and imaging tests that would otherwise be unattainable or prohibitively expensive for the patient.

How many people with breast cancer use complementary therapy?

Forty percent to 66% of patients with breast cancer report that they use at least some form of complementary therapy in addition to conventional therapy. 4 In most settings, the potential risks and benefits of adding such therapy to conventional treatment are unknown.

What is a physician's license?

As is the case with pain medication, a physician's medical license provides authority to order tests and procedures that cannot be ordered by some alternative practitioners. The physician's order implies medical necessity and is often required for insurance coverage. In some cases, an alternative practitioner may even request a procedure such as central intravenous catheter placement that might facilitate alternative therapy administration.

What is the primary obligation of a physician?

A physician's primary obligation is to the interests and well being of his or her patients. This includes not only the impetus to promote a patient's health, termed beneficence, but also an obligation to respect the patient's individual goals and preferences for his or her care, termed respect for autonomy.

Why do patients with terminal cancer need to be referred to palliative care?

Many patients with terminal cancer with no possibility of cure or disease control have to be referred to palliative care physicians for alleviation of pain, psychological distress, nutritional derangement, etc. This step necessitates the handover of care from the primary physician and his team to the palliative care team. This transition may be psychologically distressing for cancer patients and their relatives. However, clinical logic and rationalisation of cancer care for a large cohort of cancer sufferers necessitate that this transition be made when necessary. Disclosing these realities to patients and relatives is often difficult but has to be done almost as a daily routine for many. Communicating this prognostic information to patients is an area where ethical concerns often arise. Cancer care providers face dilemma in deciding whether to provide survival statistics, discuss life expectancy and poor prognosis, encourage hope and also to be mindful of various cultural and social barriers. While most studies done on this reveal that many patients want to know about prognostic information and life expectancy; exceptions also exist in the literature where patients did not want a quantitative account of the chances of cure [ 66 ]. This is more complex in cases where a patient deteriorates from curative to palliative treatment. There is varied evidence on this in the literature where some studies found that patients preferred their prognosis not to be discussed and a few other studies report patients to be well informed of expected course of illness and aims of treatment [ 66, 67 ]. In LMICs with poor literacy levels, an additional confounder worsening the ethical dilemma is the patient or family’s inability to comprehend the prognostic information provided. In addition, economic policies of a healthcare system dictate the finite and often scarce resources to be utilised towards more curative patient groups. This has resulted in a longstanding bias towards allocation of resources to palliative cancer patients. Studies have shown that the hospital expenses of care for a terminally ill cancer patient who died within 24 months were double than those cancer patients who did not die [ 68 ], other studies have shown that expenditure for cancer patients under the age of 65 grew exponentially for the terminal year and as death approached [ 68 ]. This financial and ethical challenge is faced by care providers while allocating resources to curative cancer patients versus the terminally ill.

What is clinical decision making in cancer?

Clinical decision making in cancer is a complex affair, especially in resource-poor settings. With a rapid advancement in the discovery of new cancer drugs with noted clinical benefits, the cost of treatment has also increased significantly [ 54 ]. Cancer caregivers are faced with multiple ethical challenges that arise during the course of patient care. A widely practiced model of shared decision making is adopted by many care providers but unavoidable conflict arises when the treatment plan of the physician does not match with the personal choices, economic and social burdens of his patient [ 55 ]. To what extent a cancer physician should respect the patient’s right to choose treatment is a very complex judgement. If an adequately informed patient refuses treatment, care providers have merely a limited role to play; this gets more complex for patients who opt for alternate forms of treatment during the course of their illness. LMICs experience 65% of total cancer deaths in the world with 5% of global health resources allocated for cancer control [ 42, 56 ]. In 1970, only 15% of new cancer cases were reported from the developing world, this became 56% in 2008 and is predicted to be 70% by 2030 [ 57 – 59 ]. Today, two-thirds of the 7.6 million yearly deaths from cancer happen in LMICs [ 58 – 60 ]. The challenges in the treatment of cancer in developing countries are unique and closing the gap between the rich and the poor is complex. Lack of healthcare infrastructure, low awareness in the general population, uncontrolled exposure to carcinogens, high rates of tobacco use and absence of screening programmes make cancer care in LMICs particularly challenging [ 42 ]. Technological advances in oncology are directly associated with increased cost of treatment. The advances often offer enormous benefit to the patients who can afford it; but they also lead to an economic burden on the healthcare systems, the patients’ family and the community as a whole [ 41 ]. In countries without universal healthcare coverage, the majority of treatment cost is out of pocket, which lead the family to adverse economic circumstances. The ASEAN Costs In Oncology (ACTION) study, one of the largest observational studies in Asia, which followed household burden of cancer, reports higher financial catastrophes in populations with poorer income, less access to cancer treatment and no insurance coverage [ 41 ]. Evidence like this calls for health policy actions from governments focusing on affordable and accessible cancer care. Frequently oncologists have to weigh the burden of treatment with anticipated outcome [ 61 ]. One major challenge facing healthcare institutions in developing countries is the enormous number of cancer patients reporting to tertiary care facilities because of lack of infrastructure and expertise at other hospitals to manage these patients. In India, Nearly 0.9 million cancer cases are reported each year [ 62 ]; this burden on oncology centres significantly compromises the time spent by physicians with each patient.

What is the most preventable cause of death?

Tobacco is the single most important preventable cause of death globally [ 5 ]. Tobacco use is associated with several types of cancers which are very common in LMICs contributing to 50% of all cancers in men and 20% in women [ 6, 7 ]. Globally, 90% of lung cancer deaths in men and 80% in women are attributable to smoking [ 8 ].

What is the American Journal of Bioethics?

The American Journal of Bioethics discusses the criteria for consideration before mandating a public health intervention. These ethical considerations are often highly debated in case of the HPV vaccination, especially in developing countries [ 47]

What is the ethical dilemma of health planning?

Ethical dilemma: In a resource-limited setting, health planners are faced with a dilemma to prioritise funding for preventing high rates of infant mortality through treatment of diarrhoea, better vaccination coverage and preventing other communicable disorders.

How much will cancer cost in 2030?

The cost of delivering cancer treatment is estimated to rise globally with a projected total spending of $458 billion by 2030 [ 1 ].

What are the social determinants of cancer?

The social determinants of the disease go beyond genetic dispositions and are affected by other complex factors such as cultural preferences, lifestyle choices, belief systems, stigma, etc.

Is clinical research good for cancer?

While poor clinical research, like poor conventional treatment, certainly exists, it is nonetheless true that clinical research has a permanent place in cancer treatment and provides an important alternate to cancer quackery.

Has cancer treatment improved?

Cancer treatment has improved dramatically in the recent past. As a consequence, the range of choices has been greatly broadened. With a much larger range of choices and a larger range of treatment disciplines available, decisions regarding treatment create major ethical burdens for the physician an ….

What are the ethical responsibilities of an oncologist?

An oncologist's ethical responsibilities typically begin with a positive diagnosis of cancer, an event that triggers shock and anxiety in patients and their families. Cancer is associated by many people with disfigurement, dying, and death; therefore, the first ethical duty of an oncologist and his or her team is to convey the diagnosis in a way that balances the reality of the disease and its implications with the overall need to maintain optimism and hope. Whereas the obligation to be honest about the reality of cancer derives from the ethics of truth telling in cancer care and in medicine generally (see below), the duty to foster hope taps several sources (Kodish et al., p. 2974):

Why is cancer treated aggressively?

People with cancer are treated aggressively, sometimes without much concern for their quality of life, perhaps partly as a result of the way in which cancer treatment is framed as a "war" that should be "waged" with "weapons" such as chemotherapy and radiation therapy.

Why is honesty important in cancer diagnosis?

Honest disclosures build trust and ameliorate conflict between clinicians and patients and their families.

What are the advances in cancer care?

Sophisticated diagnostic modalities aid in the timely detection of the disease. The benefits of established treatments such as chemotherapy and radiation therapy have been maximized gradually but steadily, and the risks have been minimized. Major changes in other aspects of cancer care have followed. For example, oncology personnel today pay far more attention than did their predecessors to issues such as the frank disclosure of diagnoses and treatment options, long-term quality of life for cancer patients and their families, and ethically complex scenarios that range from gaining consent from incompetent adults to the participation of children in discussions and decision making about cancer clinical trials.

What do cancer patients draw on?

Studies show, for example, that cancer patients frequently draw on religion, nature, art, the military, and many other sources of imagery to help them visualize their diseases, treatments, and recoveries (Skelton; Tompkins and Lawley).

What is the threat of cancer in Italy?

In parts of Italy cancer poses the threat of social as well as physical disruption and death, a viewpoint that meshes with the importance Italians place on defining themselves and their worth in relationship to others (Gordon).

How will cancer care be affected by the future?

Future developments in cancer care will be affected by advances in the clinical control and prevention of the disease. Ongoing genetic and molecular research promises not just more effective treatments for cancer but also less invasive procedures for patients, greater patient autonomy, and improved quality of life. Potential problems may include a compounding of concerns about informed consent for cancer clinical trials and genetic susceptibility testing, as well as more "macro" issues such as the inequitable distribution of cancer care resources in the United States and globally. Also, current trends suggest continued growth in "informal" cancer care resources ranging from online information networks to holistic alternatives to conventional cancer care. Many of these resources have the potential for linking together and empowering cancer patients but also of misinforming them or undermining the oncologist's authority and purpose through the exposure of patients to multiple, conflicting messages. Surveys and other kinds of behavioral research may be needed so that providers of cancer care may better grasp the pluralistic knowledge- and treatmentseeking tendencies of their patients and the way in which they affect physician-authority, treatment adherence, and other key clinical issues.

Abstract

Introduction

Tobacco Control: Challenges from A Low Middle-Income Tobacco Producing Country

Ethical Considerations in Research on Cancer Patients

Conclusion

Funding Statement

References