Refusal of treatment

📌 2. R v Blaue (1975, UK) — Refusal with Religious Beliefs

  • An 18-year-old stabbed in an assault refused a blood transfusion for religious reasons (Jehovah’s Witness).

  • The court held that her refusal did not break the chain of causation in the criminal case — the assailant was still responsible for her death.

  • The decision reaffirmed that competent patients’ medical decisions, even if they contribute to harm, are legally effective. Wikipedia

1. Capacity is central (Mental Capacity Act 2005)

Before accepting a refusal, a doctor must assess decision-making capacity.

Under the Mental Capacity Act (MCA), a patient has capacity if they can:

  1. Understand the information

  2. Retain it

  3. Use or weigh it to make a decision

  4. Communicate their choice

Key interview phrase:

“An unwise decision does not mean a lack of capacity.”

If capacity is present, the refusal must usually be respected — even if it leads to serious harm or death.

2. Informed refusal

A valid refusal requires that the patient understands:

  • The proposed treatment

  • Benefits and risks

  • Consequences of refusing

  • Reasonable alternatives

Doctors must explain this clearly and check understanding.

3. Adults (18+) in the UK

  • A competent adult can refuse any treatment, including life-saving treatment.

  • This includes refusal based on religious beliefs (e.g. blood transfusions).

Key case to mention (briefly):

  • Ms B v An NHS Hospital Trust (2002) — confirmed a competent adult’s right to refuse life-sustaining treatment.

4. Advance decisions (advance refusals)

Under the MCA:

  • Adults can make an Advance Decision to Refuse Treatment (ADRT).

  • If valid and applicable, it is legally binding, even in emergencies.

  • Refusal of life-sustaining treatment must be written, signed, and witnessed.

5. Patients who lack capacity

If a patient lacks capacity:

  • Decisions are made in their best interests

  • Consider:

    • Past wishes and values

    • Family input

    • Least restrictive option

Treatment cannot usually be refused on their behalf unless there is:

  • A valid ADRT, or

  • A legally appointed Lasting Power of Attorney (LPA)

6. Children and young people

This is a very common interview area.

Under 16s

  • May refuse treatment if Gillick competent

  • However, refusal can be overridden if it puts them at serious risk

16–17 year olds

  • Presumed to have capacity

  • But courts can still override refusal if refusal risks serious harm or death

Key message:

“In paediatrics, autonomy is important, but the child’s welfare is paramount.”

7. Emergencies

  • If treatment is urgently needed to save life or prevent serious harm and:

    • Capacity cannot be assessed, or

    • Wishes are unknown
      → Treatment can proceed under best interests.

8. GMC guidance (what doctors should do)

According to the GMC:

  • Respect patient decisions

  • Communicate clearly and without coercion

  • Explore reasons for refusal (fear, beliefs, misunderstanding)

  • Document discussions carefully

  • Maintain the therapeutic relationship

Interviewers like hearing:

“Refusal doesn’t end the doctor–patient relationship.”

9. Public health exceptions

Autonomy may be limited when refusal:

  • Poses serious risk to others
    (e.g. certain infectious disease controls)

10. A strong 60-second interview answer

You can say:

“In the UK, refusal of treatment is grounded in respect for autonomy, provided the patient has decision-making capacity under the Mental Capacity Act. My role as a doctor would be to ensure the refusal is informed by explaining the benefits, risks, alternatives, and consequences of refusing, and to assess capacity carefully. If a competent adult continues to refuse, even life-saving treatment, that decision must usually be respected. Exceptions include emergencies, patients who lack capacity, and children, where refusal may be overridden if it risks serious harm. Throughout, clear communication, documentation, and maintaining trust are essential.”