Ann Thorac Surg 2003;76:1337
© 2003 The Society of Thoracic Surgeons
Correspondence
Legal consequences of disregarding a patient’s wishes: Reply
Martin F. McKneally, MD, PhDa
a Department of Surgery and Joint Centre for Bioethics, University of Toronto, 77 Forest Grove Dr, Toronto, ON M2K 124, Canada
e-mail: martin.mckneally{at}utoronto.ca
To the Editor:
Counselor Ridley argues convincingly that legal documents regarding property are not subject to reinterpretation by surrogates. He overextends when he applies this argument to decisions regarding health care. Neither patients nor their surrogates are held captive by advance directives. A woman who elects to forgo analgesics and epidural blocks to participate fully in the experience of childbirth may change her mind when the pain exceeds a threshold she did not anticipate. Realizing that circumstances can change in ways that would alter their prior decision, many people favor designating a trusted relative or friend as a surrogate decision maker with the power of attorney for personal care, even if they have written an advance directive. Unfortunately, for potential organ recipients, family members commonly make surrogate decisions to override the expressed wishes and written directives of loved ones who had planned to donate their organs at the time of death.
I fully agree with the quotation from Veatch; maximizing medical well-being should not automatically override the best interests of the patients in other spheres, including religious and social fulfillment. The balancing of these values and beliefs should be the responsibility of patients or their surrogates, and physicians should respect their decisions. Maximizing medical well-being is, nevertheless, the defining responsibility of physicians; this fiduciary duty is the basis for trust in the medical profession. In communicating this foundational value to Mrs Charles, Dr Smith fulfilled his duty as he understood it. He was given valid surrogate consent to do so by Mrs Charles. Making an exception to the discharge of this responsibility by withholding lifesaving treatment would have been appropriate if she, as Mr Charles’s valid surrogate, balancing her husband’s values in the circumstances only she could witness for him, had reaffirmed the overriding importance of his religious interests. She did not; she asked Dr Smith to transfuse.
With other surgeons and patients, I am grateful to the members and leaders of the Christian Congregation of Jehovah’s Witnesses for the moral pressure and scientific support they have mobilized so effectively to reduce the use of transfused blood.
