Refusing treatment--who shall decide?

The issue of consent in medical care, and its corollary refusal of consent, has become more and more complex. Three major consent issues are: (I) the capacity of giving consent or obtaining consent when the individual involved is impaired or not competent to give consent; (2) the capacity to consent to or authorize non-treatment or withdrawal of treatment; and (3) the refusal to give consent where there is a question as to capacity to consent but where the patient is otherwise legally impaired and is under a legal disability such as involuntary commitment because of mental illness. The first issue is exemplified by situations involving minors, unconscious patients, those with transitory mental impairments due to associated physical illness, and those found to be specifically incompetent to make rational decisions (e .g., certain retarded or mentally ill individuals). Rules dealing with emergency and primacy of religious belief have been particularly scrutinized in this group. The second issue deals with brain-damaged individuals or those with hopeless physical conditions where further treatment is thought to be either fruitless or, at best, a temporary expedient to keep alive one set of organs without affecting the overall functional level of the person. The risk-benefit ratio is marked by minimal or no possibility of benefit, whatever the consid-' eration of risk or worth of monetary cost. The first two groups have been particularly applicable to general hospitals or nursing home situations. The third area is refusal of treatment or refusal of consent for treatment by a mentally impaired individual who has been involuntarily committed to an institution, public or private, in accord with the law of the state involved. At one time, the fact of commitment conferred with it the authority to treat. Sometimes this authority was specified in statutes that authorized the superintendent or medical director to authorize or delegate appropriate treatment. Sometimes, particularly when surgery unrelated to the mental condition was indicated, authority was granted to the nearest relative or in the case of emergency, to the superintendent. By inference, those working under the superintendent or medical director were authorized to proceed with procedures or treatments deemed necessary by the medical staff. Commitment was, in any case, generally assumed to carry with it the authority to treat. This authority has now been under attack for a number of years, and the rapidly evolving principle ofthe right to refuse treatment has rendered this earlier consensual system anachronistic. The evolution of legal cases dealing with consent issues in psychiatry and the practical effects of these decisions have been commented on by a number of authors. I-I I