If a competent patient refuses care, either directly or through a living will or
surrogate, the physician is bound to respect those wishes. This does not apply
to euthanasia or living wills that violate state law. Until recently, however,
physicians have been able to treat critical care patients against their will
because the courts were reluctant to punish a physician for delaying a patient’s
death. As the courts become more sophisticated about these cases, they are
less willing to tolerate these intrusions on patient autonomy. One court has
already assessed damages against a hospital that refused to terminate life
support for a patient who was brain dead. [
McVey v. Englewood Hosp. Ass’n,
216 N.J. Super. 502, 524 A.2d 450 (N.J. Super. A.D. 1987).] Courts are also
likely to assess attorney’s fees and damages against physicians who ignore
clearly effective living wills in order to avoid terminating life support.
Physicians are already seeing patients and families who reject living wills and
demand life support. Patients do not have the right to unnecessary medical
care, including intensive care that cannot affect the outcome of their condition.
If the patient demands all available care, the physician must be careful to
document the therapeutic rationale behind decisions to deny or terminate life
support for these patients. In all cases, it is easier not to start a therapy than
to terminate it. This is a very slippery slope, however, as hospitals and third-
party payers increase the pressure on physicians and families to refuse or
terminate life support.
At least one hospital openly challenged the right of patients and their families
to demand the application and continuation of life support. This hospital
sought a court order to terminate life support for a patient whose clearly
expressed wishes, and those of her husband, were to continue the life support.
The court refused the order, finding no compelling reason to overrule the
patient’s decision. Most hospitals apply less open but nonetheless real pressure
on families and physicians. Physicians should be careful that it is medical
considerations and not financial pressures that underlie the decision to refuse
life support to patients. Many physicians correctly worry about the denial of
resources to other patients with a better prognosis. This does not make
physicians who are determining the care for individual patients the proper
agents to refuse care to benefit society. Although MCOs stress cost-effective
care, this is under the constraint that the patient must receive the same quality
care. Only the government can change the legal standard and allow classes of
patients to be denied care to benefit society as a whole.