Beyond Consent: An Ethical Framework for Medical Intervention Over Objection in Incapacitated Patients

Abstract: In inpatient settings, decisions often arise regarding non-emergent medical (non-psychiatric) interventions for patients with limited decision-making capacity over their objection. Ethical conflict in these cases stems from balancing respect for patient autonomy and bodily integrity with beneficence and non-maleficence, necessitating a high threshold for justifying intervention over objection. This issue is challenging due to its common occurrence, the unique vulnerability of these patients, and the significant moral distress it triggers in healthcare teams. Rubin and Prager (2018) propose the sole framework in the literature addressing this dilemma, consisting of seven questions. However, the complexity of these clinical situations requires a more comprehensive and nuanced ethical analysis.

This paper presents a novel framework for characterizing these clinical situations and offers guidance for navigating their complexities. The framework classifies types of intervention that might be pursued and raises specific questions addressing:

1.) the patient’s decision-making capacity, including approaches for optimizing capacity and suggestions for how to best involve surrogate decision makers,
2.) the ethically salient factors of patient’s clinical condition, such as prognosis, urgency, and reversibility,
3.) the coercive measures that might be required, including the invasiveness of the measure and the degree of patient cooperation, and
4.) the distinct ethical considerations for diagnostic versus therapeutic interventions.

Finally, it provides logistical approaches for ethically appropriate interventions over objection and recommendations for proper documentation.

This framework aids in ethical decision making for complex cases and offers a broader perspective with an innovative approach, contributing valuable insights to the discourse on this topic.