REFUSAL FOR AN INCOMPETENT ADULT
a. More Steps in Honoring the Right to Refuse. When the patient cannot
express his or her wishes, important decisions are left up to the family members,
doctors, hospital administrators, and if conflict should arise, a court of law. An
incompetent adult who was previously competent has the right to refuse treatment. The
rules are generally stricter for a never competent patient because of the impossibility of
determining his or her wishes. (See anecdote, page 2-7, on John Storar, a never-
competent patient.) Because of the state's duty to protect those with limited autonomy,
more steps are involved before refusal can be authorized. These additional steps are
intended as safeguards to protect the patient from a decision that might not be in his or
her own best interests.
b. Subjective (Substituted Judgment) Standard. Under the subjective
standard, the patient's definition of "best interests" is sought, rather than some
objective standard. Thus, maximum deference is given to the patient's right to self-
determination, even if the decision is not objectively in the patient's best interest. The
subjective (substituted judgment) standard can only be applied if there is some
evidence of what the patient would have wanted. Prior oral or written directives are the
best evidence of the patient's desires. Though oral directives have been accepted by
some courts, a written directive, i.e. a living will and Durable Power of Attorney for
Health Care (DPAHC) (where applicable by state law), are easier to substantiate than
an oral directive.
SUBJECTIVE (SUBSTITUTED JUDGMENT) STANDARD
Determining what the patient would have wanted.
Using evidence of patient's prior wishes. Oral directives are preferable to
Figure 2-4. Under the subjective (substituted judgment) standard, maximum allowance
is given for the patient's right to self-determination, even if refusal is not
objectively in the patient's best interests.
c. The Objective Best Interests Standard. The best interests standard
generally requires the surrogate (next of kin, legal guardian, and so forth) to consider
such factors as relief of suffering, preservation or restoration of function, and the quality
and extent of the sustained life as viewed by the patient. The quality-of-life component
tries to determine the value of the patient's life to the patient, and does not measure the
value of life according to the patient's ability to contribute to or produce in society. If a
surrogate were to refuse beneficial treatment for no justifiable reason, that decision
would be seriously questioned.