In a case of anencephaly, where the patient, an adult with capacity, has agreed to an abortion but a relative is refusing, whose decision should prevail regarding the procedure?

Patient Autonomy Prevails in Medical Decision-Making

The patient's decision prevails (Answer B). When an adult patient with decision-making capacity agrees to a medical procedure, their autonomous decision is legally binding and ethically paramount, regardless of family objections. 1

Legal and Ethical Framework for Capacity-Based Decisions

Patient Autonomy is Paramount

• A competent adult patient's consent or refusal of treatment is legally binding, even if the decision may result in death. 1
• The patient does not need to make a "sensible, rational, or well-considered" decision for it to be valid—the decision simply must be made voluntarily by someone with capacity. 1, 2
• Modern medical ethics has shifted from physician beneficence to emphasizing patient autonomy as the primary principle in Western medical practice. 1

Capacity Assessment Requirements

The patient must demonstrate all four elements of capacity: 2

• Understanding the information about the procedure
• Appreciation of how it applies to their situation
• Reasoning through the decision
• Communication of their choice

If the patient meets these criteria, their decision stands regardless of family preferences. 2

Family Members Have No Legal Authority

• Relatives cannot override the decision of a competent adult patient. 1
• Family members should be consulted when a patient lacks capacity to help determine best interests, but they have no decision-making power when the patient has capacity. 1
• The only exception would be if the patient had legally appointed the relative as a health and welfare attorney through a Lasting Power of Attorney—but this only applies when the patient loses capacity. 1

Addressing Potential Coercion

Voluntariness Must Be Ensured

• The patient's decision must be made voluntarily, without coercion from family members or others. 1
• If there is concern that the relative is coercing the patient, the provider should speak with the patient privately, away from the potentially coercive influence. 1
• Legal advice should be sought if it's unclear whether the patient's inability to decide is due to mental impairment or external duress from family. 1

Cultural Considerations

While some cultures emphasize family-centered decision-making (Korean, Mexican-American, Asian, and others traditionally involve family in medical decisions), this cultural preference does not override the legal rights of a competent adult patient in Western medical-legal systems. 1

Documentation Requirements

The provider should document: 2

• The patient's capacity assessment
• That the patient understands the procedure and its implications
• That the decision was made voluntarily without coercion
• The family's objection and how it was addressed
• The final decision to proceed based on patient consent

Common Pitfalls to Avoid

• Never assume that family disagreement invalidates patient consent. The patient's autonomous decision takes precedence. 1
• Do not delay necessary care while attempting to achieve family consensus when the patient has already provided informed consent. 1
• Avoid conflating cultural norms with legal requirements—while respecting cultural values is important, it cannot supersede the legal rights of a competent patient. 1