Case 1

Mrs. G. has an aneurysm in her brain that, if untreated by surgery, will lead to blindness and probably death. The surgery recommended leads to death in 75% of all cases. Of those who survive the operation, nearly 75% are crippled. Mrs. G has three small children. Her husband has a modest job, and his health insurance will cover the operation, but not the expenses that will result if she is crippled.

When informed of this, Mrs. G. is in great emotional turmoil for a week or so until she makes her decision. She refuses treatment, because she does not like the odds. There was, after all, only a one chance out of sixteen for a real recovery. In addition, she could not come to grips with exposing her family to the risk of having a mother who would be a burden and not a help.

Can a patient with serious obligations, such as a family, refuse treatment? What odds of recovery would be good odds?

Case 2

Mrs. S., an 85-year-old housewife, becomes aware of breathlessness and is easily fatigued. She is known to have had a heart murmur for two years. She consents to come to a research hospital for cardiac catherization, which confirms the presence of severe, calcific aortic stenosis with secondary congestive heart failure.

Because of the unfavorable prospect for survival without surgical intervention, the recommendation at the combined cardiac medical-surgical conference is for an operation. The physician explains the situation to Mr. and Mrs. S. and recommends aortic valve replacement. It is noted that the risk of surgery is not well known for Mrs. S,'s age group, and that early mortality is usually around 10 percent, with 80 percent achieving good functional results after three years. Her lack of an obvious disease makes her a relatively good candidate for a successful surgical outcome, despite her age.

Mrs. S. appears to understand the discussion and recommendation, but requests deferral of the decision and shows signs of denial of the problem. She has no other medical problems, her husband is in good health, and their marriage appears to be happy. They are financially secure and enjoy at full set of social and recreational activities. She returns on three subsequent occasions for simple, supportive attention. The physician decides not to employ psychiatric assistance or other measures to reduce her denial and begins to use conversation to reduce her anxiety associated with her decision.

Does Mrs. S.'s apparent denial of her condition make informed consent impossible? Is the physician ethical in reducing her anxiety about her apparent refusal of treatment when the physician believes treatment is medically indicated.