GP Dr Mark Wood argues that deciding whether a patient is competent to refuse treatment is far from straightforward

The article 'What to do when competent patients refuse treatment', by Dr Gerard Panting of the Medical Protection Society (Guidelines in Practice February 2001), was interesting and wide-ranging.

The crux of whether a patient can legally refuse treatment, however, revolves around the question of competence, and on this Dr Panting provides little advice.

As he states, in order to be competent to withhold consent a patient must be able to understand the information being given, believe it, and be able to weigh it in the balance of choice.

But how can we assess these attributes independently of the choice being made? There is no generic test of a patient's ability to weigh the balance of benefit and harm. The assessment of this ability is therefore largely dictated by the doctor's judgment of the choice made regarding the treatment in question.

The argument becomes circular: the patient demonstrates that he is not competent to refuse the treatment by refusing the treatment.

Assessing the patient's ability to understand the information being given is also open to many doubts. Indeed, what level of understanding is required?

How many qualified doctors can truly claim to understand the statistical analyses at the heart of the 4S trial that are the corner-stone of cardiac risk management in relation to cholesterol? The statistics of chance are fiendishly complex. On this basis, few people taking statins really understand their risk management benefits. So how can they give informed consent – or indeed withhold it?

In the absence of clear legal parameters, such decisions will be forced on front-line doctors acting in good faith. The common law will continue to be defined by test cases around such acts, often at the personal cost of the doctors involved.

Dr Mark Wood, GP, Barnstaple, Devon

Dr Gerard Panting replies:

Dr Wood is quite right. Competence to make decisions is not an all or nothing phenomenon, but depends upon the patient's ability to understand his/her own position.

In theory the same patient may be competent to make one decision but incompetent to make another. In practice, the decision must be made by those responsible for the patient's care.

No doubt, there will be challenges to such decisions from time to time, but it is unlikely that case law will ever be developed to give clear legal parameters because it would be impossible to cater for all conceivable circumstances.

Dr Gerard Panting, Head of Policy and External Relations, MPS

As the winner of the July 2000 Guidelines in Practice competition, I went to Champneys with my wife for a two-night stay. We had a wonderful time, and were cosseted, exercised, massaged and thoroughly spoiled throughout our stay.

I would recommend all my overworked colleagues to read your valuable journal closely and enter future competitions, in the hope that they too might win a relaxing break. Many thanks.

Dr Michael O'Ryan, GP, Prescott

Guidelines in Practice, March 2001, Volume 4(3)
© 2001 MGP Ltd
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