Refusal of treatment can present some tricky ethical dilemmas

This issue includes stories on informed refusal and on managing psoriasis.

Informed consent is a commonly discussed concept, but the closely related issue of “informed refusal” raises its own set of ethical questions for physicians. Even when a treatment appears to be clearly the very best option and offers what you perceive as very little risk, your patient may still decide emphatically against it. In situations like these, how can physicians follow best practice while still respecting patient autonomy? In our story, Terri D’Arrigo looks at how the concept of “informed” should be defined and offers tips on assessing decision-making capacity, avoiding patient coercion, and discerning the real reasons behind a patient's refusal. As in many other instances, avoiding miscommunication and misunderstanding is key.

Our main clinical story in this issue delves into the difficulties of treating psoriasis. A recent survey showed that many psoriasis patients are not satisfied with their care, reporting inadequate relief from such symptoms as itching and scaling. Complicating matters, experts say, is the fact that psoriasis can be a challenge to diagnose, since it can often be mistaken for eczema and patients may shy away from reporting it when it manifests in sensitive locations. In addition, patients who have tried topical treatments with limited success may begin to feel that seeking further treatment is futile. Learn more about clues to diagnosis and suggestions on treating and managing symptoms of both mild and more severe disease.

This issue also offers several pieces in our Perspectives section. Our Washington columnist, Bob Doherty, takes an in-depth look at the Affordable Care Act in 2014 and offers readers ideas on what questions will be raised and answered during this crucial year. ACP President Molly Cooke, MD, FACP, addresses recent criticism of the College's involvement in securing access to care. And our Resident's Corner discusses how young physicians must learn to balance their professional and personal sides when family members and friends turn to them for medical expertise.

On the lighter side, try your wits at the latest version of Crossed Words. And don't forget our MKSAP quiz, which tests your knowledge in the field of Gastroenterology and Hepatology.

What are your biggest questions about the Affordable Care Act in 2014? How do you handle it when a patient tells you, “Thanks but no thanks”? Let us know.


Jennifer Kearney-Strouse