that I must have the opportunity to decide whether to accept the treatment offered
even though others may feel that I am wrong in the decision I come to.
10.8 Refusing treatment
It is clear that, in English and American law, I do seem to have the opportunity to
refuse treatment. Treatment carried out without my consent is usually actionable.
What is less clear is how far I have the right to decline treatment when such
treatment is, or is likely to be, life-saving. For though the corollary of the necessity
for consent might seem to be that, without my consent, treatment cannot be carried
out, in practice the refusal of life-saving treatment is often regarded as prima facie
evidence of an inability to give or withhold consent on a rational basis [4].
There is a troubling lack of symmetry between consenting to treatment, on the
one hand, and declining life-saving treatment, on the other. For if the moral
importance of consent is to be located in the idea of autonomy, i.e. self-determi-
nation, then choosing a course of action which you know is highly likely to result
in your death seems inconsistent with this. Self-determination disappears when
there is no self left to determine. Perhaps we can merely pass over this as a puzzling
oddity since there are many other examples of it which we accept quite readily:
people who risk their lives, and lose them, in the attempt to help others; people
who choose death rather than the violation of some principle or value which seems
to them more important than their own lives; and people who rationally choose to
commit suicide. Counselling this latter category does, however, raise some prac-
tical difficulties also thrown up in dealing with those who refuse life-saving
treatment. For the general principle that people should make their own decisions
and learn from their own mistakes cuts a little too deeply here. If choosing suicide
or refusing treatment turns out to have been a mistake, then it is, in the nature of
things, too late to learn anything from that. Just as consent can only be genuine if
the patient fully understands what she is consenting to so, equally the decision to
refuse life-saving treatment should only be respected if it is clear that the patient
understands the consequences of the refusal and also that the refusal is exactly
what it seems to be.
10.8.1 Capacity
This last point is related to both knowledge and understanding. Clearly I cannot be
said to have consented to something if I am kept in ignorance of, misled about or
simply fail to understand, its nature. Doctors, like any other group with specialist
knowledge, are capable of explaining something in such a way that no non-spe-
cialist could hope to understand it. This is much rarer than it used to be and many
doctors are now trained in communication skills. Nonetheless it is not always easy
to explain a complicated matter in terms which are both clear to the lay-person
and, at the same time, accurate and complete. Nor are patients always very good at
admitting that they have not understood a word and would like it explained again.
It is always possible, in other words, for anyone to give apparent consent which is
undermined by lack of knowledge or genuine understanding. There are, however,
214 Nursing Law and Ethics