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(Chest. 2004;126:630-633.)
© 2004 American College of Chest Physicians

On the Dilemma of Enigmatic Refusal of Life-Saving Therapy*

Katrina A. Bramstedt, PhD and Alejandro C. Arroliga, MD, FCCP

* From the Department of Bioethics (Dr. Bramstedt), and Critical Care Medicine (Dr. Arroliga), Cleveland Clinic Foundation, Cleveland, OH.

Correspondence to: Katrina A. Bramstedt, PhD, Associate Staff, Bioethicist, Cleveland Clinic Foundation, NA10, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: bioethics{at}go.com

When patients give no reason for refusing therapy (an enigmatic refusal), this creates the dilemma of whether or not to administer the therapy by force, especially when the therapy poses low risk and offers significant benefit. We argue that there is a duty to assess the patient’s decision-making capacity, as well as attempt to understand a patient’s reason(s) for refusing treatment. While some patients may not readily offer reasons for refusing treatment, this does not preclude an obligation for clinicians to inquire about such. The reasons for treatment refusal can be related to the patient’s goals, values, fears, and mental state.

Key Words: autonomy • decision making • ethics • paternalism • refusal • treatment






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