Right to Refuse Medical Treatment

All adults with decision-making capacity (i.e. able to make decisions for themselves) have the right to accept or decline medical treatment—even if decisions may result in a poor outcome, including death.  This fundamental right to refuse medical treatment is considered a negative right—the right to not be touched and to be free from unwanted medical interventions.  Overriding a decisional patient’s refusal is not ethically or legally permissible.

Even adults who lack decision-making capacity retain the fundamental right to refuse recommended treatment. Health care professionals are required to respect their refusals, except in limited circumstances as outlined below.

In ethics terms, treatment given over objection violates the ethical guideline of respect for persons and can only be justified in specific situations.

Adults with Decision-Making Capacity

Having the right to refuse medical treatment does not mean that when a decisional patient says no, that their refusal will be accepted without question. Any time a patient declines a recommended treatment, it means that they and the treating clinician view the situation differently. That is okay. It is not the patient’s job to simply “go along” with what is being recommended. Rather:

• A decisional patient’s job is to consider all the options and decide what is best for them.
• What is most important from the medical point of view may not be most important from the patient’s point of view, because goals and values may differ.
• As long as a decisional patient has been given all the relevant information about their treatment options and knows the risks and benefits of each option, including the risks and benefits of turning down treatment, the patient’s wishes come first and treatment over refusal is prohibited.

Clinicians are obligated to promote the health-related interest of their patients. They do this by making medical recommendations that support restoration of health and well-being.  When patients disagree with or refuse those recommendations,  it is ethically permissible for clinicians to encourage acceptance of reasonable medical alternatives that align with the patient’s goals and values.  This means that clinicians can respectfully persuade their patients to reconsider decisions and explore other appropriate options that align with their goals, but cannot force them to change their mind.

Adults Who Lack Decision-Making Capacity

Adult patients who lack decision-making capacity still retain the right to refuse medical treatment in all but exceptional circumstances. The two circumstances where it is permissible to treat over the objection of an incapacitated patient are:

• If the patient has waived their right to refuse in an advance directive (Ulysses Clause), or
• If the situation would result in serious and irreversible bodily injury or death if the health care is not provided within 24 hours.

These exceptions are defined in Vermont statute, which sets the threshold for when it is permissible to treat a patient who lacks decisional capacity over their refusal: [see 18 VSA §9707 (g)(1)]

A Helpful Algorithm to Determine if Treatment over Refusal Is Permissible

*Flow diagram used with permission from UVM Medical Center Departments of Clinical Ethics and Legal/Risk

Additional Information about Treatment over Refusal When Patient’s Lack Capacity