Worked Examples: A Patient Refuses Treatment
Treatment refusal is one of the most common and challenging scenarios in the UCAT SJT. It sits at the intersection of patient autonomy, beneficence, capacity, and communication — all core ethical principles that the SJT assesses.
This lesson works through multiple treatment refusal scenarios with detailed analysis of why each response is rated as it is.
The Legal and Ethical Framework
Before working through examples, you need to understand the rules that govern treatment refusal in the UK.
The Principle of Autonomy
A competent adult has an absolute right to refuse any treatment, even if that refusal will result in their death. This is a fundamental principle of medical ethics and English law.
| Key rule | Explanation |
|---|
| Capacity is presumed | Every adult is presumed to have capacity unless there is evidence to the contrary |
| Unwise decisions are allowed | Having capacity means you can make decisions others consider unwise — this does not mean you lack capacity |
| Refusal must be respected | If a patient with capacity refuses treatment, that refusal is legally binding |
| Consent must be informed | The patient must understand the nature, purpose, and risks of the treatment they are refusing |
The Mental Capacity Act 2005
The Mental Capacity Act (MCA) provides the legal framework for assessing capacity. A person lacks capacity if they cannot:
- Understand the information relevant to the decision
- Retain the information long enough to make the decision
- Weigh up the information (consider pros and cons)
- Communicate the decision (by any means)
All four criteria must be failed for a person to lack capacity. Capacity is also decision-specific and time-specific — a person may have capacity for one decision but not another, and their capacity may fluctuate.
Worked Example 1: A Competent Adult Refuses a Life-Saving Blood Transfusion
Scenario: You are a medical student on a surgical ward. Mrs Patel, a 45-year-old Jehovah's Witness, is scheduled for major surgery tomorrow. She tells the surgical team that she will not accept a blood transfusion under any circumstances, even if her life is at risk during the operation. She has signed an Advance Decision to refuse blood products.
Rate the appropriateness of each response:
Response A: "I respect your decision. Can I check that you fully understand the risks of refusing a transfusion during this type of surgery?"
Rating: Very appropriate
Analysis:
- Respects the patient's autonomy immediately
- Ensures informed consent by checking understanding of risks
- Does not attempt to change the patient's mind but ensures the decision is truly informed
- Maintains the therapeutic relationship
- Follows GMC guidance on respecting patient decisions
Response B: "I think you're making a terrible mistake. You could die without a transfusion."
Rating: Very inappropriate
Analysis:
- Judgmental and disrespectful of the patient's beliefs
- While the clinical information may be accurate, the delivery is aggressive and unprofessional
- Undermines the patient's autonomy
- Damages the therapeutic relationship
- A competent patient's right to refuse treatment is absolute, regardless of whether the healthcare professional agrees
Response C: "I'll make a note in your records. The surgical team will need to plan the operation with cell-salvage techniques and other blood-sparing methods."
Rating: Appropriate but not ideal
Analysis:
- Practical and clinically appropriate
- Demonstrates understanding that the team must adapt to the patient's decision
- However, it skips the step of checking the patient's understanding of the risks — the practical response would be stronger if preceded by confirmation of informed refusal
Response D: "Let me call the hospital chaplain — perhaps they can help you reconsider."
Rating: Inappropriate
Analysis:
- Assumes the patient has not already considered the religious and ethical dimensions
- Patronising — implies the patient's own faith is insufficient without professional religious intervention
- The chaplain may be helpful for spiritual support, but not to change the patient's mind
- Undermines autonomy by seeking to influence the decision
Worked Example 2: A Patient Refuses Antibiotics for a Serious Infection
Scenario: Mr Davies, a 68-year-old man, has been diagnosed with pneumonia. His doctor prescribes antibiotics and explains that without treatment, the infection could become life-threatening. Mr Davies says, "I don't believe in antibiotics. They do more harm than good. I'll fight this off naturally."
Rate the appropriateness of each response:
Response A: "I understand you have concerns about antibiotics. Can you tell me more about what worries you? I'd like to make sure you have all the information you need to make this decision."
Rating: Very appropriate
Analysis:
- Explores the patient's Ideas (ICE framework) without being dismissive
- Does not immediately challenge or contradict the patient
- Opens a dialogue that may reveal the patient's underlying concern (perhaps a previous bad experience with antibiotics, or misinformation from a specific source)
- Preserves the therapeutic relationship and the opportunity to provide accurate information
Response B: "That's your right. I'll document your refusal."
Rating: Inappropriate
Analysis:
- While technically correct (it IS the patient's right), this response is inadequate
- It fails to explore the patient's reasons or check their understanding
- A responsible healthcare professional should ensure the patient is making an informed decision before simply accepting the refusal
- Does not fulfil the duty to provide information
Response C: "Antibiotics are evidence-based medicine and your views are wrong. I strongly urge you to take them."
Rating: Inappropriate
Analysis:
- While the clinical information is correct, the delivery is dismissive and confrontational
- Telling a patient their views are "wrong" is unlikely to change their mind and is likely to damage the relationship
- Does not explore the patient's perspective or reasons
- A better approach is to ask, listen, and then provide information
Response D: "I'd like to explain what could happen if the pneumonia is not treated, and also address any specific concerns you have about antibiotics. Would that be okay?"
Rating: Very appropriate