as the disagreement is one in which a reasonable (lay) person could understand and endorse the patient's choice. Thus, for example, a reasonable person ...
Health professionals (nurses as well as doctors) may be concerned that, by carrying out stomach washout without consent or even by physically preventing a patient from leaving the accident and emergency department, they could be liable to prosecution by the patient. Clinical decisions must of course respect patients' rights, but these include the right to expect doctors to exercise their duty of care responsibly. 1 Mental health act 1983. London: HMSO, 1993. 2 Jones R. The mental health act manual. 4th ed. London: Sweet and Maxwell, 1994. 3 Department of Health and Welsh Office. Code of practice: mental health act
1983.London: HMSO, 1993.
receive attention. The situation is more difficult if a patient is brought in by the police or by a carer from an institution. However, in the two cases reported here the casualty officer would have known that friends or relatives were responsible for each patient's presentation. In such cases the doctor must therefore take into account the broader perspectives of each case rather than the short term demands of a patient. Decisions must be taken on the basis of previously agreed, evidence based protocols and should not be influenced by anxiety about adverse public reaction. Casualty officers must not be forced to make judgments "on the hoof." If departmental policy does not seem to be relevant to the current problem casualty officers should seek advice from a senior colleague.
Practical ethics Grant Gillett The ethical principles underlying clinical practice tend to run on two axes: firstly, the need to protect life and wellbeing, and, secondly, respect for the individual patient. Occasionally the principles of beneficence (or doing good) and respect for autonomy seem to conflict, and such situations require doctors to blend clinical wisdom and the art of negotiation. The case of head injury presented here is an example. Clearly, any reasonable patient would want to be protected from the potentially fatal effects of a head injury including a skull fracture and persistent neurological abnormalities. The patient described was not in a frame of mind to agree with this advice. Any patient can opt out of treatment, even lifesaving treatment, if that is their considered choice. But we should note that autonomy is self rule and therefore implies a level of reasonable or considered control over one's own conduct and reactions. This is implicit in the idea of a sound mind, and the test for it is that a patient is making a choice that a normal person would regard as reasonable. Note that a person is not of unsound mind solely because he or she disagrees with a doctor, as long as the disagreement is one in which a reasonable (lay) person could understand and endorse the patient's choice. Thus, for example, a reasonable person might refuse to consent to heroic surgery for a disseminated cancer or a serious intracerebral haemorrhage even when that surgery might prolong his or her life. This implies that a person could be in sound mind and refuse such an intervention even when a doctor strongly disagreed and wanted to provide treatment. In the case of the patient with a head injury I would question the patient's soundness of mind. From an ethical point of view the critical question concerns our duty to keep from harm and to benefit where possible. It is likely that this patient, having recovered from his abnormal state of mind, would have been grateful for escaping his possible brush with death. This suggests that we should carry out our duty to keep from harm.
Providing treatment against a patient's wishes D W Yates A patient who presents voluntarily at an emergency department should be assumed to want treatment. If relatives or friends bring in a patient we can again assume that they want the person in their care to 118
Head injury Admission of the patient with head injury was clearly advisable as the risk of intracranial complication was quite high. However, the patient was still fully conscious, albeit with an alleged change of behaviour, after he had been examined and had had x ray pictures taken of his skull, perhaps one or two hours after the incident. The risk of dramatic sudden deterioration at this time is extremely small. The subsequent development of an extradural haemorrhage would be most likely to lead to a gradual change in higher cerebral function over an hour at the
least. As the patient refused to come into hospital for observation, it could be argued that he should have been detained against his will. However, to physically or chemically restrain him would have complicated management and would have destroyed some of the signs that should be monitored to assess cerebral function. In such circumstances it is entirely reasonable to allow a patient to discharge himself or herself home, but only into the care of responsible relatives or friends. They would probably be as effective at monitoring the patient's condition as would a busy ward nurse. They should be made aware of this responsibility and sign a note in the hospital records to this effect. The doctor responsible must also be sure that the friends understand their role, do not leave the patient unattended until the next day, have access to a telephone, and know the telephone number of the accident and emergency department. A card should be given to the carers summarising and reinforcing this advice. If the friends or relatives are unable or
unwilling to assume this responsibility then, regrettably, the patient must be detained against his or her will. Drug overdose The case of the overdose presented the doctor responsible with two options. One was the short term approach (naloxone only), with potentially lethal long term consequences. The second-the one carried out-addressed both the short term and the long term problems of this overdose. The issues here are straightforward. To have chosen the first alternative would have been to intervene incorrectly. This is as negligent as not giving any treatment at all. The patient was brought by a concerned third party, and this person's more rational long term view of the problem must be taken into account. The problem would have been more difficult had the patient been fully conscious when he arrived at hospital, but even then the long term perspective of the carer would override the short term demands of the patient, particularly as in this case there was no history of psychiatric illness and the overdose was likely to be an understandable response to abnormal environmental stresses.
BMJ VOLUME 311
8JuLY1995
