REFUSAL OF TREATMENT – ADOLESCENT WITH CANCER Rabbi Prof. Avraham Steinberg

GENERAL CONSIDERATIONS

PRINCIPLES OF BIOETHICS AUTONOMY BENEFICENCE NON-MALEFICENCE JUSTICE

SECULAR MEDICAL ETHICS Based on the overriding principle of autonomy it is a widely accepted ethical axiom nowadays that a competent patient has the right to refuse medical interventions even if the refusal might cause him harm. Is an adolescent competent enough for such decision?

SECULAR MEDICAL ETHICS - PROBLEMS Insufficient information and explanation Lack of understanding of the facts Lack of a good physician-patient relationship Desire of the patient for more attention from the caregiver and the like Occasionally, the refusal is due to social pressure, or depression, or the influence of medications

JEWISH MEDICAL ETHICS - PRINCIPLES The validity of autonomy in halakhah is limited. A person has no right to bring harm to his body by refusing sound medical treatment. According to halakhah, the physician is obligated to heal and the patient is obligated to seek healing. Therefore, the medical treatment is often not determined by the desire and consent of the patient but by the objective facts. Coercion to accept medical therapy can be viewed as coercion to fulfill commandments.

HALAKHIC RULES AND REGULATIONS If the patient has a life-endangering illness or wound of which the physician has a complete and clear understanding and offers a standard and effective treatment, one can force the patient to accept the treatment even if he refuses. If it is necessary to desecrate the Sabbath to save life and the patient wishes to be stringent and not allow it, one should force him to accept because such a man is a pious fool. The law which requires patient coercion to accept therapy applies only to standard and effective therapy and not to situations where there is doubt about the efficacy of the proposed therapy.

HALAKHIC RULES AND REGULATIONS Even when a treatment is considered to be life-saving, if it is suspected that coercion might result in a significant anxiety which can worsen the medical condition of the patient, then coercion should be avoided. Although in principle one must coerce a patient to accept life-saving treatment even. In practice, in many instances the medical opinion is uncertain and there are doubts about certain decisions. Therefore, in such instances, one should not coerce the patient. If a patient refuses to accept a certain medical treatment because he feels that the treatment is not proved to be efficacious, one should not coerce him. If the treatment is not a standard one, and certainly if it is experimental, the patient should not be coerced.

ISRAELI DYING PATIENT ACT Article F: Treatment of the Terminally Ill Minor 24. A minor’s parent is authorized to represent him regarding his medical treatment, whether in the matter of prolonging his life or in the matter of refraining from prolonging his life … if he has no parents, or the parents’ guardianship has been revoked and no other guardian has been assigned for the minor, or if his guardian is not a close person, the institutional committee will make a decision in respect of him.

ISRAELI DYING PATIENT ACT A minor who is a terminally ill patient is entitled to participate in the adoption of a decision regarding his medical treatment, if these two conditions are satisfied: (1)The minor is aware of his condition and requests to participate in the adoption of the decision regarding him; (2) The responsible physician determines that the minor's cognitive and mental capacity and maturity enable his participation in adopting the decision regarding him.

ISRAELI DYING PATIENT ACT A responsible physician will give the minor information that pertains directly to his health or his medical treatment, if these two conditions are satisfied: (1) The responsible physician is convinced that giving the information, or a part of it, will not cause physical or mental harm to the minor, or endanger his life; (2) The responsible physician has determined that the minor’s cognitive and mental capacity and maturity enable him to appropriately understand the information and its meaning.

ISRAELI DYING PATIENT ACT (a) In the event of a dispute between the parents of a minor who is a terminally ill patient, or between them and the responsible physician, with regards to his medical treatment, an institutional committee will resolve the matter. (b) Where there is a dispute between a minor who is a terminally ill patient and his parents, or between them and the responsible physician, with regards to his medical treatment, the following provisions shall reply:

ISRAELI DYING PATIENT ACT (1)Where the minor expressed his wish for his life to be prolonged the responsible physician will act in accordance with that wish, subject to the provisions of this Law; (2)If a minor less than 15 years of age has expressed his wish that his life not be prolonged, an institutional committee will decide on the matter.

ISRAELI DYING PATIENT ACT (c) When an institutional committee discusses the matter of a minor who is a terminally ill patient, it should hear the minor’s position as well, if expressed, and the committee should also receive the particulars of the information that was given to the minor. (d) The institutional committee will take the best interests of the minor into account among its other considerations, and will be entitled to determine that his life should not be prolonged, if convinced that prolonging his life would not be in his best interests, subject to the provisions of subsection (b)(1).

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