Neurol India Home 

Year : 2016  |  Volume : 64  |  Issue : 6  |  Page : 1395--1396

Author's reply: The right to refusal: The patient's prerogative

Daljit Singh 
 Department of Neurosurgery, G B Pant Institute of Postgraduate Medical Educations and Research (GIPMER), New Delhi, India

Correspondence Address:
Daljit Singh
Department of Neurosurgery, G B Pant Institute of Postgraduate Medical Educations and Research (GIPMER), New Delhi

How to cite this article:
Singh D. Author's reply: The right to refusal: The patient's prerogative.Neurol India 2016;64:1395-1396

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Singh D. Author's reply: The right to refusal: The patient's prerogative. Neurol India [serial online] 2016 [cited 2019 Sep 19 ];64:1395-1396
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The letter by Vilanilam and Sasidharan on informed refusal has eloquently highlighted several relevant issues. It has attempted to gauge, in minute details, the issues that can entangle the process of refusal. While we often focus on consent as a process of absolute necessity, informed refusal has not become a reality yet.

The refusal only pertains to a person who is sane enough to deny the procedure even at risk to life.[1] The concept, however, is gray in several arenas. With the “philosophy of life” guiding doctors, they may object and oppose the patient's refusal as a routine practice. However, in reality, the humiliations and frustrations associated with litigations thrust upon doctors demand utmost care in obtaining consent as well as refusal.

Refusal is an unsettled paradigm and doctors should be cautious in interpreting its implications. No court will ever object to “refusal;” however, it will act with severity on a doctor who has operated or tried to convince the patient to undergo a procedure once the latter has refused. If a document has been signed on which the patient has given his/her refusal to undergo a procedure, I feel that one should refrain from trying to convince the patient again. Let the patient then decide to re-consent or consent to undergo the procedure elsewhere. It would be advisable to keep the “refusal” records.

We encountered a case of a 55-year-old female patient with subarachnoid hemorrhage, with Hunt and Hess grade 1, due to an internal carotid artery aneurysm. The patient and her relatives refused to give consent for surgery. We tried to explain all the aspects including the risk of sudden death due to re-bleeding of the aneurysm, and yet, they were not convinced. We obtained a “refusal” consent and the patient left against medical advice. A month later, the patient came A month later, the patient came back with subarachnoid hemorrhage and in a clinical status of Hunt and Hess grade IV. Some other relatives of the patient tried to confront me by questioning why the doctors in the hospital did not operate on the patient at the first instant. When we revealed the informed refusal signed by the patient and her care-givers, they could not argue any more.

The capacity to refuse is an integral component of the patient's competence in understanding the import of his/her decision. It may not be wrong to assume that refusal may have been decided based on the assumption of incompetence of the surgeon to whom that patient may have been handed over for initial care and supervision. Anxiety exhibited by the patient prior to giving his/her consent for a procedure is natural, as are his attempts at delaying or denying consent for a procedure; however, over-enthusiastic attempts in trying to convince and win over the patient and trying to reverse his decision of not undergoing a particular procedure may be counterproductive in case the results of surgery are unfavorable. This fact assumes even more importance if the patient was reluctant to undergo the procedure initially.

Courts certainly do not evaluate the intentions of the surgeon but rather act based on what is already on records.[1]

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Conflicts of interest

There are no conflicts of interest.


1Singh D, Tanshi D. Consent taking in neurosurgery: Education and tips for safe practice. Neurol India 2016;64:742-50.