You Be the Medical Ethicist

A patient came to Grady Hospital in Atlanta 12 hours after intentionally cutting off his finger.

He did not want it reattached, but a neighbor had called 911 and persuaded him to go to the ER. The patient said he owed a penance to God—a debt paid in full by severing his finger. A psychiatric evaluation showed he was of sound mind in all other aspects of his life and had no intention of further self-harm.

The Emory doctors asked for a consult with the hospital's medical ethicist: Should the finger be reattached?

The first inquiry the ethicist made was: Does the patient have the capacity to make his own decisions? If so—and assuming he is fully informed of the consequences—it is his right to refuse medical treatment, even if it is life-saving.

Generally, a person has capacity for a given decision if he (1) understands the situation and the consequences of his decision, and (2) his decision is based on rational reasons. A clear example of someone who lacks decision-making capacity is a patient with advanced dementia who can't state a preference or follow a conversation.

The team assured the ethicist that the patient was thinking clearly in all regards and understood exactly what he had done as well as the future ramifications of his actions. So the remaining question was: Is the patient's decision rational?

What, exactly, is "rational"? A lot of people do not floss despite clear benefit to their oral health. Given how easy and cheap it is to floss, it seems irrational not to do so. So should nonflossers be deemed incapable of making their own medical decisions? Likely not. 

Rational decisions are particularly difficult to assess when a person refuses medical treatment because of religious beliefs. If an adult who is a Jehovah's Witness refuses a life-saving blood transfusion, our medical community is accommodating as long as the patient is fully informed of the risks and has decision-making capacity. But if someone refused a life-saving transfusion because they claim to be a member of the Spaghetti Monster Religious Tribe, their decision seems much less rational. Yet, this patient's action also is motivated by a religious belief. Who ought to be the judge of what is rational?

In this case, the patient was determined not to have the capacity to decide because his decision was irrational: It is not a commonly held belief that penance to God ought to be paid in severed fingers.

Despite this, the medical team ultimately decided not to reattach his finger.

Why? The anticipated benefit was too small.

If the patient did not willingly participate in the difficult rehabilitation process, the finger would likely not regain function even if reattached.