Grant Gillett traces a path through the ethical complexities of a person's right to refuse treatment - even when that refusal might end in death.
The case of the woman who is in hospital and refusing to eat raises significant ethical issues about our duties to each other and our ability to intervene when a person is doing something that seems bound to end in tragedy.
The case of Margaret Page who, at 60 years old having suffered a major cerebral haemorrhage 20 years ago, is in hospital and refusing to eat, has renewed our interest in this contested area of clinical ethics and health law.
The reality is that an adult of sound mind, however disabled, has the right to consent or not consent to any medical treatment aimed at her benefit even where her life is threatened without that treatment.
The need for consent to treatment is the only basis on which healthcare teams can treat a person who is under their care.
This is modified where a patient has difficulties in communication or is unable to be part of the decision-making process, but the healthcare team should, in good faith, be fairly sure that the patient would want them to do what they are doing.
That is sometimes called implied consent and it is reasonable when either you are sufficiently well acquainted with the patient to feel confident that you understand their wishes, or where most people would agree to what you are doing and there is no reason to think your patient is different.
That is very obvious in some cases, for instance, when a person is injured and may suffer serious brain damage or loss of function if you do not act; but usually a thoughtful clinical team can get it right if they try.
In the "most-people-would-want-it" (or "objective standard") case the law refers to the doctrine of "Necessity" - doing what is needed to avoid a tragic consequence.
The possibility of a personal and more unusual decision invokes what is called "the subjective standard" in relation to informed consent: the idea that an individual may not want what most people want (e.g. because of their religious beliefs or some other reason).
Both standards are patient-centred and put a responsibility on a care team to try to do what the patient would think best, not just what they as a care team think is right.
The right to refuse treatment reinforces this point as is, as some commentators have noted, enshrined in the New Zealand Bill of Rights Act.
It is a realistic recognition that saving life or using the most technologically effective medical interventions is not always the right thing to do and that a reasonable patient might want a somewhat more peaceful regimen of care than an all-out attempt to do everything medically possible.
Healthcare professionals often find this choice hard to accommodate, but the patient-centred focus of the duty of care means that they are required to do so unless they have a reason to believe that the patient is not of sound mind in what they seem to be wanting.
The idea that the patient must be in sound mind or capable of making a reasonable decision is very important because people can go through times when they might say "I am not in my perfect mind".
That can be the case for many people from time to time when life threatens to overcome them, and significant depression is far more common in serious illness than is often appreciated.
For that reason healthcare teams tend to intervene in suicide attempts as there is often a reason why the person is vulnerable and unbalanced at the time it happens.
The law recognises this fact and allows us to act in ways that would otherwise be considered an assault to save the life of a suicide.
For that reason it is misleading to say that people have the right to commit suicide in that anybody else has the right to stop them, even over their protests, so that it is considered to be a highly unusual situation.
The most widely known case of refusal of food is anorexia nervosa, a life-threatening and contentious condition.
Many writers have written about this problem, but many informed commentators recognise its complex biological, social, interpersonal and political aspects and regard it as a cry to be noticed by a young woman who feels overwhelmed by her besetting problems of life.
One of the commentators on Margaret Page's case has somewhat misleadingly stated that doctors can use painkillers to hasten death.
They cannot.
They can use painkillers to ease pain and distress in a person who is dying regardless of the risks to life involved because, in that situation, risk to life is irrelevant, but their duty is to mitigate pain and suffering and it is a criminal act to try to bring about a patient's death by whatever means.
Having said that, it is very understandable that a patient might reach the point of saying "This is too much to ask; please let me die in peace."
And when a doctor or healthcare team understand that to be what a patient is saying to them, they are ethically obliged to comply with the patient's request.
• Grant Gillett is a professor of medical ethics at the University of Otago Bioethics Centre.
