A case study from the perspective of medical ethics: refusal of treatment in an ambulance Hasan Erbay, 1 Sultan Alan, 2 Selim Kadıo  glu 1 ABSTRACT This paper will examine a sample case encountered by ambulance staff in the context of the basic principles of medical ethics. An accident takes place on an intercity highway. Ambulance staff pick up the injured driver and medical intervention is initiated. The driver suffers from a severe stomach ache, which is also affecting his back. Evaluating the patient, the ambulance doctor suspects that he might be experiencing internal bleeding. For this reason, venous access, in the doctor’s opinion, should be achieved and the patient should be quickly started on an intravenous serum. The patient, however, who has so far kept his silence, objects to the administration of the serum. The day this is taking place is within the month of Ramadan and the patient is fasting. The patient states that he is fasting and that his fast will be broken and his religious practice disrupted in the event that the serum is administered. The ambulance doctor informs him that his condition is life-threatening and that the serum must be administered immediately. The patient now takes a more vehement stand. ‘If I am to die, I want to die while I am fasting. Today is Friday and I have always wanted to die on such a holy day,’ he says. The ambulance physician has little time to decide. How should the patient be treated? Which type of behaviour will create the least erosion of his values? INTRODUCTION In Turkey, the official medical emergency dispatch system that manages health calls and the dispatching of ambulances is the hotline ‘112’. This study will examine an incident between a patient who is making a decision and ambulance staff to render this patient emergency medical intervention, from the perspective of medical ethics. THE EVENT On Friday, 26 September 2008, an accident occurs on the intercity highway. Onlookers call 112. According to the information they supply, there is one injured person involved in the accident. The 112 control centre dispatches the closest ambulance team to the scene of the accident. 1 The injured person is the driver of the vehicle, travelling alone. The driver has been removed from the vehicle with the help of persons from passing cars and he is conscious. Having arrived at the scene, the 112 ambulance staff pick up the injured driver and medical intervention is initiated. The injured man has a severe stomach ache that he can feel in his back. He describes the pain as intermittent, surrounding his waist like a belt. Apart from some small scratches on his face, there is no active bleeding. There is also no visible bleeding in the abdomen. A physical examination indicates that the patient’s blood pressure is low (100/60 mmHg), his pulse is weak and his ECG is normal. After about 5 min, his blood pressure is measured again and seen to be even lower (80/ 50 mmHg). The patient’s respiration is troubled. However, listening to lung sounds indicates that both lungs are equally participating in respiration. The patient asks to have the cervical collar removed because it affects his breathing. The ambulance physician making the evaluation, suspects that the patient might be experiencing intra-abdominal bleeding. Because blood loss is suspected, the patient must quickly be administered serum by venous access. The healthcare team starts to make preparations for the administration of the serum. The patient, however, who has so far kept his silence and watched the procedures, not being very involved and in fact absorbed in his own pain, suddenly objects to the administration of the serum. The day this is taking place is within the Islamic holy month of Ramadan and the patient is fasting. 2 The patient states that his fast will be broken and his religious practice disrupted in the event that the serum is administered. The ambu- lance staff member informs him that his condition is life-threatening and that the serum must be administered. The patient now takes a more vehe- ment stand. ‘If I am to die, I want to die while I am fasting. Today is Friday and I have always wanted to die on such a holy day,’ he says. The ambulance team tries to make a quick assessment about whether this decision of the patient is a conscious one and whether the patient is aware of its possible consequences. The ambulance physician has little time to decide what to do. The patient is rapidly losing blood. The blood loss must be urgently replaced with the serum. Yet the patient does not accept this. THE CASE Analysing the matter from a religious perspective is outside the scope of this paper. It would be useful, however, to examine the religious assertions that the patient has made in refusing medical treatment. The ultimate decisions about life and death are not simply medical decisions. 3 The use of religious references in refusing medical treatment is not a phenomenon that has been newly encountered. There have been many instances of ethical and legal discussions related, for example, adherents of Jehovah’s Witnesses. 45 Living and wishing to shape their lives according to religious teachings are of 1 Department of Deontology and History of Medicine, Cukurova University, Adana, Turkey 2 Cukurova University Adana Health High School, Department of Midwifery, Adana, Turkey Correspondence to Dr Hasan Erbay, Cukurova University, Department of Deontology and History of Medicine Balcali Kampusu 01330 Yuregir, Adana, Turkey; hasanerbay@yahoo.com Received 22 January 2010 Revised 17 May 2010 Accepted 13 June 2010 Published Online First 26 July 2010 652 J Med Ethics 2010;36:652e655. doi:10.1136/jme.2010.035600 Clinical ethics group.bmj.com on November 27, 2014 - Published by http://jme.bmj.com/ Downloaded from