Unreasonable obstinacy: Ethical, deontological and forensic medical problems

Especially in oncology and in critical care, the provision of medical care can require therapeutic choices that could go beyond the patient’s will or intentions of the protection of his health, with the possible adoption of medical behaviors interpreted as unreasonable obstinacy or, at the opposite extreme, as euthanasia. In some cases, the demand for obstinate therapeutic services could come from the patient or from his relatives, in which case the dilemma arises for the health professional between rejecting such a request, in respect of their professional autonomy, or abiding by it for fear of a professional care responsibility for therapeutic abandonment. We analyzed and commented on emblematic clinical cases brought to court for alleged wrong medical conduct due to breach of the prohibition of unreasonable obstinacy. In healthcare it is impossible to fix a general rule defining any therapeutic act as appropriate, because on one hand there are technical assessments of medical competence, and on the other the perception of the patient and of his family members of the usefulness of the health care provided, which may be in contrast. The medical act cannot make treatments that are inappropriate for the needs of care or even be unreasonable; conversely, before the request by the patient or by his family members for disproportionate health services in relation to the results they may give in practice, in compliance with the legislative and deontological provisions, the doctor can refuse them, thus safeguarding both his decision-making autonomy and, therefore, his professional dignity. Significance for public healthThe aim of our research is to contribute to identify the technical parameters and the ethical and deontological aspects useful to qualify a treatment as obstinate, to ensure on the one hand a treatment process that does not exceed the patient's requests or expectations (especially if unexpressed), and on the other hand to protect health workers from charges of professional liability for overtreatment damages, while avoiding attitudes of defensive medicine. Reference to the current code of Italian medical deontology is helpful in making therapeutic choices. It recommends the physician not to undertake diagnostic procedures and therapeutic interventions that are clinically inappropriate and ethically disproportionate and against the current laws, according to which the patient cannot demand healthcare treatments contrary to the law, deontology and good clinical-care practices.