What are my rights to refuse medication and other treatments?

Unlike involuntary hospitalization where issues of safety trump autonomy, the right to refuse treatment

continues to be sacrosanct (except as noted in Question 89 regarding the use of "chemical restraints"). In general, patients have the absolute right to refuse medical or psychiatric treatment of any kind, short of emergency hospitalization for issues of safety. The clinician must obtain informed consent before prescribing any treatment. Informed consent[1] is a legal and ethical doctrine fundamental to modern medicine. The process of obtaining informed consent includes the following elements:

• Assessment of the patient's capacity to make medical decisions

• Absence of coercion of the patient

• Fully informing the patient of his or her diagnosis and prognosis, risks versus benefits of the treatment offered, risks versus benefits of alternative treatments, and risks versus benefits of receiving no treatment

There are few but notable exceptions to informed consent. These exceptions include emergencies, therapeutic privilege, therapeutic waiver, and implied consent. In many emergency situations the patient is unconscious and in need of life-saving treatment. Informed consent is assumed or obtained to the best of the clinician's ability. When clinicians assume therapeutic privilege, they are withholding information from the patient because they believe that informing the patient will cause more harm than good. Occasionally, patients will request not to be informed. In other words, they waive their right to be informed. Such a waiver is not advisable. One should enlist the aid of a family member to make decisions when one wants to remove oneself from the decision. Finally, implied consent occurs when one offers one's arm to have blood drawn or their blood pressure checked.

In general, patients have the absolute right to refuse medical or psychiatric treatment of any kind, short of emergency hospitalization for issues of safety.

When refusing medication or treatment it is important to be informed of and understand the potential consequences of refusing. Understanding the consequences requires one to have the capacity to refuse treatment. The capacity to refuse treatment requires four elements:

1. The ability to express a choice

2. The ability to understand the treatment options and their consequences

3. The ability to appreciate the information as it applies to one's specific situation

4. The ability to reason with the information

All four elements must be met for a patient to have the capacity to decide on medical or psychiatric treatment. Obviously, most of these elements are generally understood between the patient and the clinician in most treatment decisions. These become important to sort out more clearly when someone is in a life-threatening situation and is refusing a life-saving treatment. Under those circumstances a physician may call in a psychiatrist to evaluate one's capacity to refuse treatment, and if one lacks such capacity, the psychiatrist may recommend an emergency conservatorship to help make such decisions. Usually, a family member is appointed the conservator under those circumstances.

There are fewer, although real, life-threatening psychiatric conditions even after someone has been hospitalized. The most obvious is when a patient remains out of control behaviorally and requires a chemical restraint. Less obvious is a patient so severely depressed that he or she is no longer eating or drinking and is refusing all treatment. Under these circumstances, in most states, a conservator-ship hearing will only allow for medical treatments to maintain the person's life but will not allow for the administration of psychiatric treatment if that individual continues to refuse that form of care. In fact, conservators generally only have the right to make decisions about medical care, housing, and finances. Conservators cannot sign someone into a psychiatric hospital, and they cannot agree to have a person forcibly medicated. Instead, a second hearing must occur, during which independent psychiatrists review the case and report their findings to the court. Only then will a judge determine whether a person can receive psychiatric care against his or her will in the form of medication or some other therapy. This procedure typically occurs after a patient is hospitalized but continues to refuse medication. Under such circumstances the hospital pursues this course of action because it is believed that the patient's health and well-being depend on treatment.

As an outpatient, it is important to understand and weigh the treatment options to the best of one's ability and to enlist outside support from other informative sources if needed. The right to refuse medication as an outpatient is respected most of the time. In fact, few states allow for involuntary outpatient treatment. This is changing, however, in very specific and limited circumstances. Recent high-profile cases in various states where noncompliant mentally ill patients have injured or killed someone have prompted new involuntary outpatient treatment laws. However, the requirements imposed on caregivers for making their case for involuntary treatment are exceedingly stringent and require regular court review.

  • [1] the premise that patients have a right to determine what happens to their bodies and as such agreement to a treatment requires receipt of information, competence to make the decision, and agreeability for the treatment.
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