Refusing life-saving surgery: respecting a capable adult

A competent adult has an absolute right to refuse any medical treatment, even when the refusal will lead to death and even when the treatment is straightforward and likely to succeed. This principle is settled in Australian common law and reflected in the Medical Board of Australia's code of conduct, Good Medical Practice. Treatment given against a competent refusal is an assault.

Capacity is decision-specific and is presumed in adults. A person has capacity for a decision if they can understand the relevant information, retain it, weigh it in reaching a decision, and communicate their choice. This man has done all four: the information was explained carefully, he repeated it accurately, he has given a coherent reason grounded in his own values, and his refusal is consistent. There is no depression, delirium or intoxication to undermine it.

Capacity is judged by the process of the decision, not by whether the doctor agrees with it. An 'unwise' choice, or one that most people would not make, is not evidence of incapacity. Ordering a psychiatric review to find a way around a competent refusal misuses the assessment.

The Mental Health Act permits treatment of a mental illness without consent in defined circumstances. It does not authorise physical treatment of a person who has capacity and no mental illness. Guardianship laws and substitute decision-makers, including next of kin, only come into play when the person lacks capacity, which he does not.

The correct course is to accept his decision, confirm it is informed and voluntary, document the discussion thoroughly, and turn to palliative care: analgesia, comfort measures, support for the family, and, if it can be arranged safely, transfer home as he wishes. The door is left open: he can change his mind at any time.