Case: Ms Ng
Opting for Chinese over Western medicine
– 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:
- 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.
- 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.
- 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.