Patients Right Of Self Determination – Law Notes – Law Tribune

What is Self-Determination ?

The psychologists who developed self-determination theory defined self-determination as follows: “Self‐determination means acting with a sense of choice, volition(will), and commitment, and it is based in intrinsic motivation and integrated extrinsic motivation” (Deci & Ryan,).

In medical ethics self-determination or autonomy refers to the freedom of every individual to make free decisions, without any pressure or coercion, as regards the methods of investigation, lines of treatment and surgical procedure. Every individual has right to make his own informed choices. He alone can decide what is to be done to his body.

Based on this principle, a doctor is bound to seek(receive)  the informed consent of the patient before he starts any investigation or treatment. He cannot disregard the patient’s wishes and instructions.

The Doctrine of Self-Determination postulates that, “ Every competent adult patient, has right to refuse full or part of method of investigations or treatment, after the full disclosure of the risk involved, in a method of investigations, or treatment or surgical procedure by the medical practioner”.

A Doctrine of self determination hold that, “A competent adult is entitled to reject a specific treatment or all treatment or to select an alternative form of treatment-even if, the decision may entail, risks, as serious as death and may appear mistaken in the eyes of medical prosession”. The doctor cannot disregard the patient’s instructions.

Every person has a right to self-determination in respect of the medical treatment that they receive. This right was famously affirmed by Cardozo J in the landmark US case of Schloendoff v. Society of New York Hospital:

“… Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent, commits an assault”.

It was reaffirmed by Lord Donaldson MR (in the UK case Re T, 1992 4 All E R 649): An adult patient who … suffers from no mental incapacity has an absolute right to choose whether to consent to medical treatment, to refuse it or to choose one rather than another of the treatments being offered … This right of choice is not limited to decisions which others might regard as sensible. It exists notwithstanding that the reasons for making the choice are rational, irrational, unknown or even non-existent.

In the same way, Butler-Sloss said in Re MB that:

A mentally competent patient has an absolute right to refuse to consent to medical treatment for any reason, rational or irrational, or for no reason at all, even where that decision may lead to his or her own death.

** It follows that a mentally ill person cannot exercise his right of self-determination, as he cannot be considered to be a competent person. Equally so, a minor also does not fall within this expression.

** In cases of emergency, however, the doctrine of necessity protects a doctor for giving treatment to a patient-or even operating upon him-without waiting for the patient to exercise his right of self-determination, as when patient is unconscious, provided that this is done in the best interests of the patients.

** When there is an epidemic or rampant spread of a contagious disease, the duty of the State to preserve the health and lives of its citizens would override the individual’s right to self-determination, as a particular course of action may become necessary to eliminate a health threat to the community at large.

** What if patient suddenly become incapacitated, or is unable, for some reason, at that time, to express any wish about his medical care ?

Now, a patient can predetermine the medical care he wishes to receive in such an eventuality. By making his wish known to his relatives and his medical attendant before such eventuality takes place.

** Today a patient can, in writing, delegate to another person in near relation the power to make a medical decision in such an eventuality.

In Nancy B vs. Hotel-Dieu de Quebec, (1992) 86 DLR (4 th ) 385  decided by the Quebec Supreme Court. (Dufour J) : The plaintiff, aged 25, suffered for two and a half years from an incurable neurological disorder that left her incapable of movement. She could breathe only with the assistance of a respirator. With it, of course, she could live a longer time, but without it, her life would be shorter. Her intellectual capacity and mental competence were unaffected. She wanted discontinuance of the treatment. To establish her right to refuse further treatment, (including the continued use of the respirator), she commenced an action for an injunction against the hospital and as also her physician to require them to comply with her decision for stopping the respiratory support.

The Court held that the plaintiff was entitled to the injunction. Permission should be given to her physician to cease treatment with the respirator at a time chosen by the plaintiff. The physician was entitled to the assistance of the hospital.

Cruzan v. Director, Missouri Department of Health is a case decided on June 25, 1990, by the United States Supreme Court holding that a state may require clear evidence of an individual’s desire to end life-sustaining treatment before a family may be permitted to end life support. 

The case: Nancy Cruzan was in a car accident that left her in a vegetative state(alive but not showing any sign of brain activity). Cruzan’s parents requested that the hospital terminate her life support, but the hospital staff refused to comply. The staff argued that the State Living Will statute required clear evidence that Cruzan had a desire for her treatment to be terminated. The Missouri Supreme Court ruled in favour of the hospital, arguing that the right to refuse medical treatment did not apply in this situation.

Impact : Cruzan v. Director, Missouri Department of Health established that the right to refuse medical treatment cannot be exercised by an incompetent individual. As a result, states may require clear evidence that the individual had a desire to end life-sustaining treatment before a family member may end life support. The decision in this case established that states’ interest in preserving life may outweigh the right to refuse medical treatment, but ultimately determined that it is up to the states to decide what evidentiary requirements should be in place.

The view expressed in a case of Secretary of State for the home department v. Robb is that the right of an adult of sound mind to self determination would prevail over any interest of the state, as a result, the prison officials, physicians and nursing staff responsible for the care of a prisoner of sound mind-who went on hunger strike-had to abide, and observe, his refusal to take or receive nutrition, by mouth or by artificial means, as long as he had a capacity to refuse the same and could not force him for such supplements.

“A prisoner of sound mind has the same right to carry on a hunger strike to death, as anyone else. The fact of his imprisonment could not displace that right”.