Balancing the duty of care with patient autonomy:
A patient’s right to refuse medical treatment
Medical Academic Perspectives 01 - November 2024
A recent judgment handed down by the Eastern Cape Division of the High Court (East London Circuit Court) highlighted the nuances of alleged medical negligence in circumstances where a patient refuses medical treatment.
The plaintiff, acting in her capacity as mother and natural guardian of her minor child, instituted an action against the MEC for Health claiming damages on behalf of her minor child whom she alleged suffered from hypoxic ischemic encephalopathy (HIE) due to oxygen deprivation during labour. The allegations centred around three key points:
- The hospital staff’s failure to adequately monitor the plaintiff’s labour and foetal heart rate;
- The administering of Misoprostol, commonly used to induce labour, which the plaintiff alleged was excessive and resulted in tachysystole (excessive contractions), which in turn contributed to foetal distress;
- The hospital staff’s failure to perform a timely caesarean section, which if performed timeously, would have avoided the brain injury.
The defendant denied the allegations of negligence on the basis that the hospital staff had acted within acceptable standards and that any complications suffered by the plaintiff and her child were exacerbated by the plaintiff’s own actions, being her refusal to allow maternal and foetal monitoring which hampered the hospital staff in performing their duties towards the plaintiff and her child.
According to the hospital records, the plaintiff repeatedly removed the cardiotocography (CTG) device which was critical to monitoring foetal heart rate. She refused to remain on the hospital bed and resisted routine examinations by the hospital staff.
The defendant pleaded that the doses of Misoprostol administered were within safe limits and consistent with the World Health Organisation’s Guidelines. Both parties’ expert witnesses agreed that the administering of Misoprostol showed no signs of tachysystole, and that the contractions observed were mild.
Very importantly, the defendant led the evidence of its factual witnesses, being the doctor who performed the caesarean section and the midwife who attended to the plaintiff during her labour. They testified that the caesarean section was scheduled at the earliest feasible time, however, due to the plaintiff’s uncooperative behaviour, including refusal to allow the hospital staff to monitor both her and her child, and to allow routine examinations and interventions, the caesarean section was delayed.
Oral evidence was led by other factual witnesses, including the anaesthetist, who confirmed that the plaintiff was aggressive, violent, vulgar and acted in a manner which made it impossible to perform routine assessments on her prior to the caesarean section being performed.
What is of great significance is that the plaintiff’s repeated refusal to allow monitoring, treatment and care was documented at length by the hospital staff in her medical records. It was noted in the hospital records that the caesarean section was to be performed on the patient who was uncooperative, at “risk, bleeding, hysterectomy, infection, injury to bladder bowl, injury to baby’.
The court held in favour of the defendant and stated that there was no negligence on the part of the hospital staff in providing reasonable treatment and care to the plaintiff and her child. The court held further that the hospital staff administered Misoprostol appropriately and with caution. There was no evidence of excessive uterine contractions and that any side effects were unlikely to have impacted the foetus by the time the caesarean section was performed.
It was held further that the hospital staff’s reaction to the plaintiff’s failure to cooperate, including their attempts at counselling her were reasonable. Further that the decision to proceed with a caesarean section was the only viable option which was delayed by the plaintiff’s continued resistance even upon reaching the doors of the operating theatre.
The court emphasized that, while healthcare providers have a duty to provide reasonable treatment and care to patients, patients retain their autonomy to refuse such treatment and care. In this case, the court recognized the limitations faced by the hospital staff which restricted them from performing their duties to the plaintiff and her child.
Key take-aways from the judgment
The principle of patient autonomy is deeply rooted in South African law.
The Constitution guarantees the right to bodily and psychological integrity. This right affirms the principle that individuals have the freedom to make informed choices about their healthcare, including the right to refuse treatment, even if it might put them at risk.
Under South African law, healthcare providers are bound by a duty of care to act in a manner consistent with the general standard of skill and diligence expected from a reasonable practitioner in similar circumstances.
Informed consent is a foundational concept in healthcare law which embodies a patient’s right to be informed of risks, alternative options and the costs associated with treatment. The principle extends to informed refusal to consent where a patient refuses to consent to treatment despite being made aware of the potential consequences associated with failure to consent
The court confirmed that patient autonomy which includes informed refusal to consent must be respected. The plaintiff was repeatedly informed of the risks associated with refusing monitoring, including potential harm to the foetus, and her refusal and failure to cooperate placed the hospital staff in a difficult position which required them to balance the duty of care owed to the patient with the patient’s right to refuse treatment and monitoring.
The case furthermore demonstrates the converse of the doctrine of volenti non fit injuria (“to one who consents, no harm is done”). While traditionally applied in cases where patients agree to treatment despite known risks, the principle may also apply to patients who refuse treatment with a full understanding of the potential consequences.
The judgment serves as a critical reminder to healthcare practitioners and healthcare facilities to ensure that robust protocols and procedures are implemented in obtaining informed consent or refusal to consent, and to ensure that all interactions with patients are documented in detail.
What is clear is that thorough contemporaneous medical records are of paramount importance in defending an action. Good recordkeeping practices should be implemented at all times and not only when informed consent or refusal to consent to treatment is being obtained from a patient. Hospital records serve as documentary evidence in demonstrating that the hospital staff acted reasonably in the circumstances.
Well-defined hospital guidelines are vital in managing cases where patients refuse treatment and should include steps to be taken in counselling the patient, obtaining informed consent/refusal to consent, and escalating decisions to senior medical staff. They protect not only patients’ rights but also those of healthcare providers from potential liability.
Hospital staff must receive training on all guidelines and must be made aware of the importance in complying with the guidelines for purposes of navigating medical negligence claims.
The judgment is also of relevance to professional indemnity insurers. Comprehensive risk assessments and policy reviews can ensure that coverage adequately accounts for scenarios where patient cooperation is a significant factor in medical negligence cases.
The case is PM obo YM v Member of the Executive Council for Health: Eastern Cape (EL1118/2022) [2024] ZAECELLC 41 (20 August 2024)
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