Reason and Rationality in Treatment Decisions

First do no harm – the oath may be sacrosanct, but what can clinicians do when reality, and patient rights, get in the way?

Two cases discussed at the Clinical Ethics Forum involved the refusal of treatment for very serious health matters. The first patient was a young man who was diagnosed with an acute subdural haematoma, possibly caused by a traumatic head injury. He was conscious and, as per his score on the Glascow Coma Scale, was deemed to have minor brain injury but not significant enough to be considered incapacitated (in terms of deciding about his treatment). The treating neurosurgical team sought to secure his consent to perform a craniotomy which is the standard treatment in such cases. The patient seemed to understand the risks of not proceeding, which included disability and death, but refused to have the procedure nevertheless. His reason was that he felt that a traditional healer could heal him by ridding him of the bewitchment that had caused the haematoma, and this would be less invasive and less dangerous than the proposed surgery

The second case involved a pregnant woman who developed a post-partum haemorrhage. On admission, she had informed the treating team that her religion precluded her from receiving blood products, even in life-threatening situations. After her bleed had started, she was offered but refused a blood transfusion. As her condition worsened, the team pleaded in vain with her to change her mind. When she ultimately slipped into a coma, the clinicians turned to her husband, legally the surrogate decision-maker at this time; he too refused on the grounds of their shared religion.

These cases led me to think about the concepts of reason and rationality. The terms seem to be inextricably related to each other in the sense that we consider a (good) reason to be one that is rational, and a bad reason to be one that is irrational, but the question I was struck by in our discussions was whether this relationship is as simple as it appears.

The reactions of both treating teams was the same: the decisions of the patients to refuse treatment that could prevent death were irrational. This view seemed to be shared by many participants in the respective sessions who were visibly unsettled by the cases (as were the members of the treating teams). While most people accepted that patients have the right to refuse treatment, the general consensus was that there should be ‘good’ reasons for doing so and, quite simply, religious and cultural beliefs were apparently not considered good reasons.

What seemed to underpin this view was what philosophers often refer to as ‘objective morality’ – the idea that moral principles and values are universally true and exist independently of individual opinions or cultural norms. On this view, actions are deemed to be right or wrong regardless of personal beliefs or societal context.

Objective morality stands in contrast to: moral relativism which is the view that moral standards are ‘relative to’ different societies or different individuals; and moral scepticism, the view that moral knowledge may be – or is - impossible to obtain. Both these theories reject the idea of universal or absolute moral truths: there is therefore no such thing as something being right or wrong for all people, at all times, in all places (and even if there was, we could not know this). In essence, moral relativism and moral scepticism justify the claim central to moral subjectivism - that what is right for you may not be right for me.

In the two cases, it was clear that (potentially) dying for the sake of a cultural or religious belief – the action believed to be right by the patients – was not the action believed to be right by the clinicians who were motivated by their oath to do no harm and saw dying from a preventable death as the ultimate harm. While acknowledging the rights of autonomous patients to refuse treatment, the clinicians seemed unable or unwilling to accept that an autonomous person would make decisions on the basis of such ‘bad’ reasons.

Pugh (2020) reminds us of a judgement in a famous case concerning an adult refusal of treatment where Lord Donaldson of Lymington made the following observation:

‘An adult patient who … suffers from no mental incapacity has an absolute right to choose whether to consent to medical treatment … This right of choice is not limited to decisions which others might regard as sensible.’

While I have absolutely no doubt that in both cases, the motivation of the treating teams was entirely altruistic and that their only concern was for the lives of their patients, I left the sessions reflecting on the need to consider that we may sometimes call people irrational not because they lack an ability to reason but simply because we disagree with their reasons. This is not to say that anything goes when it comes to moral reasoning as is sometimes taken to be the claims made by moral relativists. Nor, however, is it an argument for moral objectivism. It is instead a reminder perhaps of the importance of recognising that even autonomous, rational people may not share the same set of values and thus what counts as a good reason for one, may not count as a good reason for all.