HLTH 3100 Week 4 Informed Consent Analysis Example

One Refusal, Three Tests: Capacity, Disclosure and Voluntariness Applied One at a Time to Mrs. Alvarez's Refusal of Cardiac Catheterization

Student Name

Walden University

HLTH 3100: Ethical and Legal Issues in Healthcare

Instructor Name

Month Day, Year

One Refusal, Three Tests: Capacity, Disclosure and Voluntariness Applied One at a Time to Mrs. Alvarez's Refusal of Cardiac Catheterization

The Scenario and the Approach

Mrs. Alvarez is 74 and was diagnosed with early Alzheimer's disease a year ago. She lives with her daughter. After chest pain while gardening, she had a stress test that suggested a blocked coronary artery, and her cardiologist recommends cardiac catheterization, a procedure that threads a catheter to the heart to look for blockages and, if one is found, may open it with a stent. Mrs. Alvarez refuses. She says she does not want "tubes in her heart," that her husband died after a heart procedure and that she would rather take medicine and "see what happens." Her daughter is upset and has told the nurse her mother "doesn't understand anymore" and should be made to have it. The scenario is invented for this assignment.

Informed consent, and informed refusal, are usually described as requiring three elements: the patient has decision-making capacity, the patient has received adequate information, and the decision is voluntary (Beauchamp & Childress, 2019). The tempting move in this case is to fold them into a single verdict, either she has dementia so she cannot refuse, or she said no so that is the end of it. This paper tests each element separately and reaches a verdict on each before reaching an overall conclusion.

Test 1: Capacity

Capacity belongs to a particular choice at a particular moment; it is not a label a person carries. Early Alzheimer's disease leaves many people fully able to make some decisions, and the diagnosis alone settles nothing. Appelbaum (2007) lists four abilities that clinicians check when judging capacity for a treatment decision: whether the patient can say what she wants, whether she has taken in what she was told, whether she sees that it is about her own heart, and whether she can compare the options.

Applied to Mrs. Alvarez. She communicates a clear and consistent choice. When the cardiologist explains the procedure in plain language, she can say back that a tube goes to the heart to look for a blocked artery and that a stent might be placed. She appreciates that the problem is hers: she says, "they think my heart is blocked." Her reasoning is the uncertain part. Her refusal is linked to her husband's death after a heart procedure, which is a reason grounded in her own experience, though not necessarily in the facts of her case. Reasoning from personal experience is not a sign of incapacity; many people without dementia reason this way.

Verdict on capacity. Judged on what the scenario shows, Mrs. Alvarez is able to make this particular choice. Because her diagnosis creates real doubt, the cardiologist should document a structured assessment of the four abilities, and if doubt remains, request an evaluation by a clinician experienced in capacity assessment.

Test 2: Disclosure

Adequate disclosure means the patient has been given the information a reasonable person would want in order to decide: the nature of the procedure, its expected benefits, its risks, the alternatives and the likely consequences of refusing (American Medical Association, n.d.).

Applied to Mrs. Alvarez. The scenario shows that she was told what the procedure is. It does not show whether she was told the specific risks, which are generally low, or the alternatives, such as medical therapy alone or a noninvasive imaging test, or what refusing could mean, such as the chance of a heart attack. Her comment about her husband suggests she may believe the procedure is more dangerous than it is for her. If so, her refusal rests on a gap in disclosure, not on a stable preference.

Verdict on disclosure. Incomplete. Before her refusal is accepted as informed, the cardiologist should explain the risks in numbers she can follow, the alternatives and the consequences of refusing, and should ask what happened to her husband, since his experience may have involved a different procedure or condition.

Test 3: Voluntariness

A decision is voluntary when it is free from coercion and undue manipulation. Persuasion with reasons is acceptable; threats and pressure that override a person's will are not.

Applied to Mrs. Alvarez. The pressure here runs in the opposite direction from what consent rules usually worry about. Her daughter wants her to accept the procedure and has said she should be made to have it. Mrs. Alvarez's refusal is, so far, holding against that pressure, which suggests her choice is her own. The risk to voluntariness would arise if the team let the daughter's distress lead them to treat Mrs. Alvarez as incapable, or if the daughter pressured her into consenting later.

Verdict on voluntariness. Her current refusal appears voluntary. The team should speak with her privately as well as with her daughter present, so that any later change of mind can be confirmed as hers.

Overall Conclusion

Taken one at a time, the three tests give a clearer answer than any single verdict could. Mrs. Alvarez appears to have capacity, and her refusal appears voluntary, so her decision cannot be overridden because of her diagnosis or her daughter's wishes. But disclosure is incomplete, so her refusal is not yet informed. The right next step is neither to accept the refusal as final nor to pursue the procedure against her will. It is to complete the disclosure, in plain language and with time to think, document a structured capacity assessment and then respect whatever she decides. If, fully informed, she still refuses, the team's obligation shifts to supporting her chosen path, medical therapy and close follow-up, as well as possible.

The separation also protects her. Blending the elements would have let her diagnosis, a fact about capacity, decide a question that was really about disclosure.

A short note on the daughter is also in order. Her distress is understandable, and she should be included in the conversation if her mother agrees. She may also need information herself, including about what support her mother will need if she declines the procedure and her symptoms return, and who to call if they do. Treating the daughter as part of the care team, rather than as an obstacle, makes it more likely that whatever Mrs. Alvarez decides will be carried out safely at home.

References

American Medical Association. (n.d.). Informed consent (Code of Medical Ethics Opinion 2.1.1). https://code-medical-ethics.ama-assn.org/ethics-opinions/informed-consent

Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840. https://doi.org/10.1056/NEJMcp074045

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.