What are positive & negative rights?
When patient requests conflict with a physician’s concept of acceptable practice, it’s important to examine the distinction between positive and negative rights.4 When considering medical encounters, most ethicists focus on patient autonomy in terms of negative rights—that is, the right to decline a treatment or test.
The American Medical Association Code of Ethics states the patient has the right to make decisions regarding the healthcare that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment.5 The emphasis of informed consent promotes appropriate barriers to prevent patients from receiving care or interventions that are contrary to their desires or beliefs. Respect for patient autonomy, however, also governs positive rights—the right that something be done. Much less guidance is provided to physicians in this regard. If physicians are to respect patient autonomy by way of positive rights, how are physicians ever justified in denying a patient’s request?
According to the ACP Ethics Manual, the patient–physician relationship entails special obligations for the physician to serve the patient’s interest because of the specialized knowledge that physicians possess, the confidential nature of the relationship, and the imbalance of power between patient and physician.6
In this case scenario, the patient’s autonomous decision conflicts with the physician’s professional duty to look out for the patient’s best interests and welfare (i.e., beneficence). Therefore, we must carefully consider the balance between respecting the patient’s right to share in the medical decision making and the physician’s responsibility to avoid patient harm (i.e., nonmaleficence). This patient is so worried about having an autoimmune disease that her quality of life is compromised. When patients request diagnostic studies that are not indicated, physicians should first seek to understand the reason for the request. Then, the physician should educate the patient about his or her rationale for not recommending the test based on the physician’s specific knowledge and medical expertise for which the patient is seeking counsel.
When the risk of harm to the patient significantly exceeds the potential diagnostic utility of an intervention, the physician has to keep in focus one of the principal precepts of bioethics: primum non nocere (first, do no harm).
What if, despite education of medical necessity & risk-benefit ratio of intervention, the patient continues to insist on the nonindicated intervention?
If the principles of patient autonomy, beneficence and nonmaleficence were the only factors being weighed in such encounters, physicians may convince themselves that acquiescence to patient requests can be justified on grounds that reduction of anxiety alone may tip the risk-benefit scale toward intervention.
