RA Patient Refusing Relief: Whose Right to Decide?

September 24, 2014

A patient with rheumatoid arthritis declines to take pain relievers. His wife says he needs them, but won't admit it. What should be done?

Stonington SD. A Piece of My Mind: Whose Autonomy?  JAMA (2014) 312:1099-1100. doi:10.1001/jama.2014.8273

This essay recounts the case of a 64-year-old man with rheumatoid arthritis who refused to take to take nonsteroidal anti-inflammatory drugs for pain, which the author had recommended adding to his methotrexate. The patient's wife said, “It is just part of his self-image to be tough and not treat his pain. But he needs treatment, whether he will say so or not.”

This brought to mind a similar experience while the author was doing anthropological fieldwork on end-of-life care in Northern Thailand. Medical staff and the son overruled the wishes of an elderly man with colorectal cancer, who underwent repeated resuscitation at his son's insistence but died before a planned surgery.

Had doctors violated his autonomy? The author, a Westerner, thought so. But a Thai nursing student argued that he was "thinking like a foreigner." The father's role, she said, is to say he is ready for whatever comes. The son's role is to try everything possible until the end. "They both do the right thing," she said, "and they both get merit.”

The essay goes on to discuss the relationship between patient autonomy and the role of the family and others, and how “merit” relates to the Asian concept of karma.