cancer diagnosis little of what is said in the remainder of the consultation is heard
let alone taken in. Therefore to ensure that consent can be given to any treatment
proposed, it seems particularly important to handle carefully the transition
between the initial information about disease status and later discussion about
treatment choices.
7.9 The right to refuse or accept
It could be argued that many health care professionals perceive consent as rela-
tively unproblematic for as long as people make the choices they expect them to
make. However, it should be allowed that an autonomous patient might choose not
to follow medical or nursing advice, hence Gillon's requirement that we
acknowledge a right to acceptandaright to refuse. Some refusals will be the
product of misinformation, ignorance or cognitive impairment, but many will be
as a result of a difference of opinion or belief between the patient or patient's
guardian, and the health care professional.
The reasons for the difference could differ. Some people might attach them-
selves willingly and strongly to cultural or spiritual/religious beliefs which place
them under particular moral obligations, which in turn means that they accept a
certain loss of control over their choices without necessarily losing their autonomy.
So, for example, a devout Catholic might refuse an offer of antenatal screening for
Down's Syndrome because she knows that her beliefs exclude the possibility of
terminating the pregnancy. Others might have very particular views about how
they want their life to be shaped, and particularly how they want it to end, and they
would make their choices consistent with these goals and standards, possibly even
refusing life-saving treatments.
In the case of the person with religious views, the situation is complicated by the
fact that we sometimes have a very narrow conception of the types of choices
autonomous people make, and the types of belief that they can acceptably attach
themselves to. We seem to have little difficulty in allowing some religions to
determine the choices people make for themselves, yet in other cases we find the
beliefs and consequent choices more difficult to accept. For example, a profes-
sional might allow that a devout Catholic would choose to risk a life-threatening
tenth pregnancy rather than use contraceptives, whereas the same person might
find it more difficult to accept a Jehovah's Witness rejection of a life-saving blood
transfusion. It could be argued that the difference here is not between the choices
being made, both of which could have devastating effects, but in our attitude to the
two bodies of faith, one of which is considered mainstream and acceptable, the
other less so [23].
In fact it could be argued that the perceived difference between these cases is the
result of mere prejudice, given the equivalence of the consequences. Given this
danger it is worth remembering that one obstacle to respecting the autonomy of
others and their right to refuse might be the fact that we operate in an ideological
context which is quick to define ideas outside the mainstream as inappropriate
subjects of rational choice.
Hence the need to combine a commitment to respect for autonomy and the
Consent and the Capable Adult Patient 127