Patient Choice vs. Patient Life: In a 2023 study, researchers examined the medical needs of elderly individuals with cognitive impairments who lived alone. Many physicians interviewed acknowledged that some patients required more supervision or care, yet they deferred to patient autonomy, allowing them to return home despite risks. This raises a pressing ethical question: Are clinicians prioritizing competency and patient rights over patient well-being?
Defining Harm in Medical Decision-Making
Patient Choice vs. Patient Life: The phrase “First, do no harm” is central to medical ethics, but determining what constitutes harm is increasingly complex. For example, many medications carry severe, even fatal, side effects. Are these risks sufficiently considered before prescribing? Does the probability of an adverse effect influence a physician’s decision? And if so, what threshold justifies withholding a medication?
Traditionally, the patient defines the seriousness of risk. A clinician fulfills their ethical duty by informing the patient—both verbally and in writing—about potential side effects above a defined severity level. However, when a patient lacks the ability to manage their own care or comprehend critical health information, discharging them home solely based on their preference may pose a greater harm than limiting their autonomy.
A Preventable Tragedy: When Autonomy Overrides Safety
Years ago, I encountered an elderly woman with moderate Alzheimer’s and COPD who relied on supplemental oxygen. Before hospitalization for a COPD exacerbation, she used a rolling cart to move her oxygen cylinder around her apartment. To simplify her mobility, the respiratory therapy team planned to discharge her with a 25-foot nasal cannula, eliminating the need for the cart.
I strongly objected, knowing from extensive time spent with her that she would struggle with the long tubing. However, the hospitalist dismissed my concerns, citing her decision to return home as justification. The next morning, her housekeeper found her entangled in the tubing, suffocated on the floor. Did she even realize she was dying?
This tragedy could have been prevented. The hospitalist assumed competency without requesting a mental status assessment (MSA). Had he acted on my observations or previous neuropsychological evaluations, a competency hearing could have led to guardianship and safer discharge planning. Unfortunately, many clinicians mistakenly view patient autonomy as an absolute right—regardless of mental status.
Systemic Barriers to Ethical Care
Even when clinicians recognize high-risk situations, fragmented health and social services limit their ability to intervene quickly. Multiple agencies, each with its own regulations and bureaucratic constraints, prolong the process of securing necessary care. Research and experience confirm that appropriate placement in an assisted living facility can take months, even in urgent cases.
Does this systemic dysfunction absolve physicians of ethical responsibility? That depends on how urgently and persistently they advocate for their patient. A patient’s mental deficiency should be documented early in their medical record, but cognitive impairment—especially mild cases—may not be obvious at first. Nurses often detect subtle signs before physicians and should actively report concerns rather than merely noting them in the chart. A competency assessment should be requested immediately to allow time for intervention before discharge. While this alone won’t resolve long-term placement delays, it alerts social services and enables home visits that may protect the patient before legal action is finalized.
Breaking Down Silos: A Call for Action
For decades, experts have emphasized the need for interdisciplinary cooperation to accelerate assistance for high-risk patients. However, caseworkers remain overwhelmed, and high-risk patients are often treated as routine cases, delaying critical interventions.
Consider another preventable case: A patient with a degenerative lung disease required an expensive medication that his insurance wouldn’t cover. His physician documented that every day without the drug caused irreversible lung damage, yet approval took six weeks. By then, his condition had worsened significantly—shortening his life.
The solution is clear but challenging. Local, cross-disciplinary committees must be established to define high-risk criteria, develop fast-track protocols, and prevent system abuse. Given regulatory constraints, state involvement may be necessary. While reforming bureaucratic structures isn’t easy, it’s essential to ensure that preventable deaths don’t continue unchecked.
Join the Movement: Advocate for Patient Well-Being
The choice between patient autonomy and patient safety should never be taken lightly. Clinicians, policymakers, and healthcare professionals must work together to prioritize well-being over rigid interpretations of competency.
At Stanford Physician Advocate, we are committed to reshaping healthcare policies and advocating for ethical, patient-centered reforms. Visit StanfordPhysicianAdvocate.org to join the conversation, support advocacy efforts, and stay informed on critical healthcare issues.
📖 Source: Original article by M. Bennet Broner