Patient’s refusal of emergency care and the right to self-determination: A case report and related ethical and legal aspects
Keywords:
refusal, self-determination, consentAbstract
Background: Consent and refusal of care are pivotal issues in clinical practice, underscored by the legal protection of self-determination. Obtaining informed consent is a rigorous process requiring clear communication to enable patients’ autonomous decisions. When a patient with legal capacity refuses care, clinicians have a legal and ethical duty to assess decision-making capacity, verify understanding of the risks and benefits, communicate the consequences of refusal and propose appropriate alternative interventions, respecting the patient’s will. In emergency situations, this process is further complicated by time pressures and other patient related factors.
Methods: We report a case involving a legally competent patient with bowel ischemia who refused emergency surgical intervention, described in accordance with the CARE guidelines. The case was identified during routine clinical practice and selected due to its ethical and legal relevance in the context of treatment refusal in emergency care. Clinical data were retrospectively collected from medical records, including clinical notes, diagnostic findings, and documentation related to informed consent and refusal. The patient’s decision-making capacity was clinically assessed and documented by the treating physicians. The information provided to the patient regarding diagnosis, prognosis, risks, benefits, and available treatment alternatives was documented. The case was analyzed from a medico-legal perspective by comparing clinical management with current ethical principles on informed consent and refusal of treatment.
Conclusion: The fundamental right of patient self-determination, exercised through consent or refusal, must be respected in all clinical settings, and healthcare practitioners are obliged to provide adequate information to support informed decision-making. Meticulous documentation of the entire decision-making process is essential to safeguard both patient rights and clinicians’ legal responsibilities.
References
1. Council of Europe. Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine (Oviedo Convention, ETS No 164). Council of Europe; 1997. Available from: https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164. Accessed: 10 Nov 2025.
2. Savulescu J, Kerridge IH. Competence and consent. Med J Aust. 2001;175:313-5. doi: 10.5694/j.1326-5377.2001.tb143589.x
3. Pallocci M, Treglia M, Passalacqua P, et al. Informed consent: legal obligation or cornerstone of the care relationship? Int J Environ Res Public Health. 2023;20:2118. doi: 10.3390/ijerph20032118
4. Comitato Nazionale per la Bioetica. Rifiuto e rinuncia consapevoli al trattamento sanitario nella relazione paziente-medico. 24 ottobre 2008.
5. Beauchamp TL, Childress JF. Principles of biomedical ethics. 8th ed. Oxford: Oxford University Press; 2019.
6. UNESCO. Universal declaration on bioethics and human rights. Paris: UNESCO; 2005. Available from: Universal Declaration on Bioethics and Human Rights - UNESCO Digital Library. Accessed: 19 Jan 2025.
7. Ciliberti R, Alfano L, Robba C, Patroniti NA. End of life in Italy: ethical and legal perspectives. Healthcare (Basel). 2025;13:666. doi: 10.3390/healthcare13060666
8. Vergallo GM, Marinelli S, Di Fazio N, Zaami S, Frati P. Assisted suicide for irreversible patients on life support. Healthcare (Basel). 2025;13:885. doi: 10.3390/healthcare13080885
9. Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007 Nov 1;357(18):1834-40. doi: 10.1056/NEJMcp074045.
10. Marco CA, Brenner JM, Kraus CK, McGrath NA, Derse AR. Refusal of emergency medical treatment: case studies and ethical foundations. Ann Emerg Med. 2017;70:696-703. doi: 10.1016/j.annemergmed.2017.04.015
11. Lippert GP, Stewart DE. The psychiatrist's role in determining competency to consent in the general hospital. Can J Psychiatry. 1988;33:250-3. doi: 10.1177/070674378803300403
12. Legge 9 gennaio 2004, n. 6. Introduzione nel libro primo, titolo XII, del codice civile del capo I, relativo all'istituzione dell'amministrazione di sostegno. Gazzetta Ufficiale della Repubblica Italiana. 2004.
13. Bellino F, Tom L. Beauchamp – James F. Childress: i principi della bioetica e l’utilitarismo. Rev Études Benthamiennes. 2020;18. doi: 10.4000/etudes-benthamiennes.7898
14. Probst MA, Kanzaria HK, Schoenfeld EM, et al. Shared decisionmaking in the emergency department: a guiding framework for clinicians. Ann Emerg Med. 2017;70:688-95. doi: 10.1016/j.annemergmed.2017.03.063
15. Delbon P, Salvetti M, Paini A, Muiesan ML, Capasso E, Conti A. Refusal of blood transfusion by Jehovah’s Witnesses in Italy: legal and ethical issues. Minerva Med. 2017;137(2):37-42. doi: 10.23736/S0026-4849.17.01764-3
16. Furlan E, Giannini A. Irrational refusal of medical treatment: ethical considerations. Minerva Anestesiol. 2025;91:214-9. doi: 10.23736/S0375-9393.25.18656-2
17. Slowther AM, McClimans L, Price C. Development of clinical ethics services in the UK: a national survey. J Med Ethics. 2012 Apr;38(4):210-4. doi: 10.1136/medethics-2011-100173.
18. Fox E, Myers S, Pearlman RA. Ethics consultation in U.S. hospitals. Am J Bioeth. 2007;7:13-25. doi: 10.1080/15265160701202925
19. Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the ICU. Crit Care Med. 2008;36:953-63. doi: 10.1097/CCM.0b013e3181659097
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