Intended for healthcare professionals

Editor's Choice

In the patient’s best interests? Who says?

BMJ 2015; 351 doi: (Published 05 November 2015) Cite this as: BMJ 2015;351:h5920
  1. Fiona Godlee, editor in chief, The BMJ
  1. fgodlee{at}

“For moral autonomy it is more important to make ‘wrong’ choices than to obey instructions,” writes Michael Fitzpatrick in this week’s Head to Head debate (doi:10.1136/bmj.h5654). A ban on smoking in psychiatric hospitals would, he says, cause distress to patients and conflicts with staff. Mental health clinicians should focus on the treatment of mental illness and leave wider health decisions “to those entitled and qualified to make them—the patients.”

But what are the limits to patients’ autonomy? How much should clinicians constrain choice in the name of a patient’s best interests? On the other side of the debate Deborah Arnott and Simon Wessely say that they can’t condone “patients smoking themselves to death while in our care” (doi:10.1136/bmj.h5654). England’s Court of Appeal has ruled that smoking is not a fundamental human right, and since one London trust adopted a smoke free policy, quit rates have increased, respiratory health and sleep patterns have improved, cannabis use has fallen, and staff have more time for patients.

So where does patient autonomy meet medical responsibility? “Doctors deny patients treatment all the time,” writes Margaret McCartney (doi:10.1136/bmj.h5312). “We are meant to act in the ‘best interests’ of patients, but a patient may have radically different views from us on what those interests are.” Should you, for example, prescribe the contraceptive pill to a 35 year old smoker who knows the risks? Picking up the theme, Krishna Chinthapalli (doi:10.1136/bmj.h5828) says that it may be justifiable to refuse a patient’s request if the treatment is outside your competence or has no basis in science, if the patient’s lifestyle raises unacceptable risks, or if you feel personally threatened or abused.

McCartney concludes that it should usually be possible to negotiate a reasonable path of mutually acceptable risk, with the risks to doctors being to their registration, reputation, and conscience. Add to this the risk of a malpractice claim. A study published this week in The BMJ finds that US doctors who used more tests and treatments were less likely to be sued (doi:10.1136/bmj.h5516). Is this a charter for defensive medicine? It’s hard to know, says the accompanying editorial (doi:10.1136/bmj.h5786) if there were fewer errors and adverse events (which this study can’t tell us), this may be due to better medical care.

The balancing act between doing more or less for your patients may never have needed more skill than now. And if in the end you conclude that there is nothing you can do to help your patient, Nick Wood asks you to think again (doi:10.1136/bmj.h5037). “Even when you cannot cure us, your continuing guidance and support are crucially important to patient morale and engagement,” he says.


Cite this as: BMJ 2015;351:h5920


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