Ms. Ng is a 66-year-old woman who is an herbalist and rarely gets sick. She attributes her good health to her careful attention to her diet and use of traditional Chinese medicine. She is a single mother who raised her son, Tom, now in his 40s, while keeping up her small herbal medicine shop. However, over the last two months, she experienced worsening cough, shortness of breath, and swelling in her face. At Tom’s insistence, she reluctantly went to the hospital A&E. On a chest x-ray, a large mediastinal mass was found. Her doctor explained that the mass was compressing a large vein in her neck called the superior vena cava which was the reason for her shortness of breath and facial swelling. She was admitted to the medical ward, steroids were started, and a core biopsy of the mass was obtained.

Unfortunately, the biopsy results revealed diffuse large B-cell lymphoma and oncology was consulted. The oncologist, Dr. Yim, explained the treatment options with Ms. Ng and Tom. The bad news is, she said, that this type of cancer is very aggressive. Without treatment, the cancer will progress quickly and will be fatal in a matter of weeks. The good news is, if cancer treatments involving chemotherapy and immunotherapy are initiated, there is a 50% chance of long term cure. Even if the treatments fail to cure her, there is still a 60% chance of controlling her cancer for quite some time. “If I were you, I would start these treatments in the hospital right away,” she recommended.

Ms. Ng shook her head. “I don’t believe in your medicines, doctor. I will go to a traditional Chinese medicine practitioner who I know will help me.” Tom, however, was very alarmed. “Mother, if you don’t start these treatments in the hospital now, it may be too late!” Still, she refused and asked to be discharged.

Meanwhile, the ward physicians and nurses tried to convince Ms. Ng to start the cancer treatments. Dr. Yim arranged for cancer survivor volunteers to meet with Ms. Ng to share their experience. Still, nothing changed Ms. Ng’s mind. Dr. Yim had further meetings with Ms. Ng and her family including her son and her sister. While Tom continued to beg his mother to reconsider, his sister supported her decision. Knowing that Ms. Ng is a strong believer in Chinese medicine her whole life, her sister said, “Her mind is made up. I can only support what my sister thinks is best for her.”

After the meeting, Tom pulled Dr. Yim aside to speak with her alone. “I know my mother said she doesn’t want the cancer treatments, but I think she’s a making a mistake!” he exclaimed. “Please save her, Dr. Yim!” Dr. Yim knows that Ms. Ng is of sound mind and is capable of making her treatment decisions. However, she’s very uncomfortable herself with the patient’s decision and wonders if there’s anything else she can do.

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Themes: Patient Autonomy, Beneficence, Decision-making capacity, Cultural beliefs, Traditional Chinese medicine, cancer, family conflict, moral distress

- Dr. Derrick Au Kit Sing, Director, CUHK Centre for Bioethics

Mentally competent adult patients have the right to refuse to consent to medical treatment for any reason, or even no expressed reason at all, even where that decision may lead to death. The underlying ethical principle is to respect a person as an autonomous agent. Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London, advocates this emphasis on autonomy, describing it as “primus inter pares” (“the first among equals”) among the four ethical principles put forth by Beauchamp and Childress.¹ In philosophical ethics this has been disputed but medical practice do in fact abide by the absolute requirement of obtaining informed consent.

However, it is important to remember that refusal of medical treatment by the patient is not a permanent, irreversible refusal. In this case, Ms. Ng did in fact change her mind about immediate discharge from the hospital, and stayed on to complete the course of steroid treatment. This is a good indication that: Firstly, she is not giving up on herself and, secondly, when symptoms are significant, she may concede to receiving Western medicine treatment to an extent. Note also that in any patient first receiving the diagnosis of cancer (or other life-threatening illness) it may take time to ‘swallow’ the news and to accept the full implications of a treatment decision. Ms. Ng has a strong personal belief in traditional Chinese medicine, but she is also another human being facing a life-threatening illness for the first time. It would be important to attend to her emotions, explore her underlying concerns and the reasons for her reluctance to use Western medicine. Continuous dialogue and reassessment of her choice and preferences over time may be useful, and indeed ethically required.

In this case, there are at two other aspects worth discussing:

1. Traditional Chinese medicine as a treatment option: The case doctor and the son are particularly uncomfortable, even distressed, that Ms. Ng should refuse a rather evidenced-based efficacious treatment. What is unknown in this case is whether well-practiced Chinese medicine may also have efficacy. Certainly traditional Chinese medicine has generally much fewer controlled studies as evidence, but it would be a valid question to ask an informed Chinese medicine practitioner, or to search medical literature on the subject. A physician who pays respect to the knowledge base of traditional Chinese medicine is also indirectly respecting the patient’s such preference. By doing so, he/she may also be more effective in arguing that the recommended treatment is better than Chinese medicine for this malignant lymphoma condition.

1. The son and the sister holding different views: On whether to respect the refusal of treatment by Ms. Ng, the son focused on the missed benefit (‘beneficence principle’) while the sister was inclined to respect the autonomy of Ms. Ng. If one does agree that, philosophically, respect for autonomy is indeed “the first among equals”, should one then take side with the sister against the son? This however is not a good approach in handling disagreement among family members, as it may escalate the conflict rather than help its resolution. Rather, it may be more helpful to acknowledge that both are acting from what they think is best for the patient. Alternative options may be explored with the Ms. Ng and her family such as a time-limited trial of treatment with Chinese medicine and if disease progression continues, then switch over to Western medicine if her health condition allows.

Reference

1. Gillon, Ranaan. Ethics Needs Principles-Four Can Encompass the Rest-and Respect for Autonomy Should be “First Among Equals”, Journal of Medical Ethics 29:307-312,2003.