Case No. 5: A dying homeless man refuses treatment.
A homeless man entered the hospital with chronic gangrene, osteomyelitis, and diabetes. Doctors could tell that he had a psychiatric condition, but the patient refused to have interventions of any kind; he didn’t allow doctors to treat him with medication or submit to a psychiatric evaluation. He claimed to want simply to be fed, given his insulin, and given a bed. He was also difficult with the nurses, throwing urine at them and making them generally uncomfortable. Doctors tried to coax him into accepting intravenous antibiotics, but he refused. The choice: send him back to the street, a possible violation of the “First do no harm” oath, or seek a court order declaring the man incapable of making decisions for himself, essentially forcing him into the doctors’ care.
For a busy staff dealing with an uncooperative patient, the instinct might be to send him back to the street. But there’s no gray area here: “Discharging this very sick man to the street to die is ethically unacceptable,” says Nancy Dubler of Montefiore. The dilemma becomes how to respect the patient’s desires and treat his illness. A patient has a right to be mentally ill, says Nancy Berlinger of the Hastings Center, “but we don’t want a mentally ill person to suffer because his illness tends to make him say no.” Doctors have to determine if the man can make his own decisions; if not, a surrogate must be found. In this case, psychiatrists can be called in, even against a patient’s wishes. “Under New York law, patients certified by two physicians to be a danger to themselves or others can be held against their will in a psychiatric unit,” says Deborah Korzenik of Beth Israel. A court order can then be obtained to treat the mental illnesses. In the best-case scenario, the man would respond to that treatment, then agree to medical care. If he still refuses, doctors can seek another court order to appoint a surrogate to oversee his continued care.
The ethics team enlisted the help of a psychiatrist to determine whether the patient had decision-making capacity. She was able to have a conversation with the patient that made clear he was not capable of making decisions. During that conversation, the man allowed doctors to call his mother. She confirmed the man’s mental illness and encouraged the hospital to force him into care. The hospital sought, and was granted, permission to treat the man against his will. After seven weeks of medical and psychiatric treatment, he was released into a chronic-care facility under the supervision of his doctor, who continued to act as his surrogate.