Education And Debate

The law on managing patients who deliberately harm themselves and refuse treatment

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7214.905 (Published 02 October 1999) Cite this as: BMJ 1999;319:905
  1. Barbara Hewson, barrister at law
  1. Littman Chambers, 12 Gray's Inn Square, London WC1R 5JP
  • Accepted 16 August 1999

A recent BMJ paper on managing patients who harm themselves and refuse treatment produced many responses on our website questioning the legality of the advice. Some of these letters are published on p 916. We commissioned Barbara Hewson, a barrister with a specialist interest in the subject, to clarify these issues.

Letters p 916

Managing patients with deliberate self harm who refuse treatment in the accident and emergency department is a complex issue. Hassan et al devised one such hypothetical case, found that doctors were not clear about how to approach it, and proposed an algorithm of their own to guide management.1 As the subsequent correspondence to the BMJ's website shows, some readers are unconvinced by the algorithm. Broadly, I think it provides a helpful summary.

Professors Ian Kennedy and Andrew Grubb, who edit a recent textbook on medical law, say that “Interventions (including medical treatment) may be justified at common law to the extent that it is reasonable to do so in the circumstances, and providing what is done is reasonable, where the competence of the individual is unknown. The common law justification of ‘necessity’ would come to the aid of the doctor … an apparent suicide victim may be treated to save her life unless it is absolutely clear that the patient was both attempting to kill herself and was competent at the time to make that decision.”2 This approach may provide some comfort for doctors who prefer to “treat now, dispute later.” However, it does not encompass the problem posed by an adult patient who is alert, conscious and refusing life saving treatment for deliberate self harm. Such a person is presumed competent to refuse, in the absence of evidence to rebut the presumption. When a patient who is not obviously incapacitated (for …

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