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Respecting an autonomous decision to refuse life-saving treatment: a case study

02 August 2020
Volume 12 · Issue 8



Autonomy is a key ethical principle in healthcare, giving patients the right to be involved in their own care. Allowing patients to make decisions based on their own values and beliefs is a fundamental aspect of evidence-based practice. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical situations which can affect the way a paramedic performs their duty of care. Decision-making is a fundamental skill for paramedics and often in the prehospital setting, paramedics have to manage situations with a certain degree of risk if they are to manage patients effectively and safely, while respecting patients' legal and ethical rights.

Case presentation:

An ambulance crew were called to attend a 62-year-old woman with a history of chronic obstructive pulmonary disease, respiratory arrest and stage 2 respiratory failure, who had breathing difficulties. She was deemed to have capacity by the ambulance crew under the Mental Capacity Act. The patient refused to be taken to hospital for treatment against paramedic recommendation, as she wished to receive no further treatment or hospital admission and wanted to die at home. The ambulance crew referred her to her GP.


Paramedics experience great difficulties in making decisions, as information and alternative treatment options are often limited in the prehospital setting. One major limitation to autonomy is where an autonomous patient is refusing life-saving treatment. This can create ethical dilemmas for paramedics, leaving them to feel a sense of vulnerability and anxiety around performing their duty of care. The law is clear: an autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998.

Beauchamp and Childress (2013) originally developed four principles of biomedical ethics—autonomy, beneficence, non-maleficence and justice—to analyse and improve ethical situations in healthcare (Aldcroft, 2012). Autonomy is defined by Beauchamp and Childress (2013):

‘in which autonomous patients are choosers who act intentionally, with understanding, and without controlling influences that determine their actions’.

Respecting a patient's autonomy means acknowledging that adults who have decision-making capacity (Kukla, 2005) have the right to make informed, uncoerced decisions regarding their own care (Finch, 1981; Willis and Mehmet, 2015). It also gives them the right to take actions based on personal values and beliefs (Stiggelbout et al, 2004; Beauchamp and Childress, 2013), even when their decision challenges clinicians' advice (Sedig, 2016). Minkoff (2014) emphasised that autonomy is a key ethical principle in healthcare which takes precedence over other principles. Sedig (2016) agreed, as patient independence is one of the highest priorities in medicine. Collen (2017) discussed how autonomy develops barriers in healthcare, diminishing what is important in patient care.

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