para 2-11) was concerned that the individual, not knowing the full range of possible
options, might think that his or her only choices were death or a lower quality of life.
c. Life-Saving Treatment for Minors and Incompetent Patients. When the
patient is a minor or incompetent, courts are more likely to authorize even major life-
saving interventions, unless the patient is terminally ill or irreversibly comatose. Courts
will authorize some treatments for pregnant women to preserve the life of the fetus,
immediately before and during birth.
d. Overriding a Patient's Refusal of Care When the Patient is in Pain. When
a patient refuses care because of pain and discomfort, the patient's ability to determine
his or her own best interests is put into question. In such circumstances, the court
allows the physician to operate somewhat paternalistically (in an authoritative, "a father
who knows best," manner). The physician cannot simply respect the patient's wishes
when pain may be obscuring judgment. The spouse and/or family are asked to
communicate the urgency of the situation to the patient. (See the Dax Cowart case,
below.)
DAX COWART, ATTORNEY AND BURN VICTIM, MAINTAINS THAT BURN
VICTIMS ARE COMPETENT TO KNOW IF PAIN IS TOLERABLE OR NOT
In 1978, Dax Cowart suffered critical burns in a propane-gas explosion near
Henderson, Texas. The pain was so excruciating that he begged a passing farmer for
a gun with which to kill himself. En route to the hospital, he implored the medic to let
him die. For more than a year, and against his will, he went through extremely painful
treatments. His right eye and several fingers were removed; his left eye was sewn
shut. He was in constant pain and kept demanding that treatment be stopped. One
night, he crawled out of bed to try to throw himself out of a window, but was discovered
and prevented. Although Cowart was able to piece together a new life after the
accident (married and a law school graduate, he is living in Texas and managing his
investments), he remains adamant in the conviction that physicians violated his right to
refuse treatment. He regularly addresses ethics groups to get his message across. "It
doesn't take a genius to know that when you're in that amount of pain, you can either
bear it or you can't. And I couldn't," says Cowart.17 (Doctors were following standard
guidance that patients in great pain are not competent to make judgments.) But
contends Cowart, the patient's rights are compromised in a no-win situation. When the
patient initially refuses care "...it's the pain talking. And then when narcotics are given
to subdue the pain, they say it's the narcotics talking."18 In Cowart's case, doctors
acted paternalistically (in an authoritarian, "father knows best" manner). They
overruled his pleas in the belief that he would one day recover sufficiently to be
grateful. Health care ethics classes often view a film depicting Cowart's injury,
excruciating treatment, and recovery when considering the state interest in the sanctity
of life versus a patient's right to autonomy.
MD0067
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