Patient Rights, Consent, and Agency in Anorexia Care

Introduction and the Patient Bill of Rights

June is a 34-year-old divorced woman diagnosed with severe anorexia who has been hospitalized. Her doctors believe she may need to be placed on a feeding tube to save her life. Initially, June agreed to the feeding tube; however, during the evening — before the tube was placed — she became combative and disoriented and refused the procedure. Her mother and father insisted that the feeding tube be inserted despite her refusal. Her ex-husband wished to uphold June's decision. The hospital administrators sought risk management and legal counsel.

The Patient Bill of Rights articulates U.S. federal law on the doctor-patient relationship and is consistent with laws on informed consent, where licensed professional practice respective to patient well-being is required. Confidentiality of patient records is perhaps the most critical factor in assessing June's capacity as a party to her own treatment once her retracted decision regarding feeding tube insertion is overruled. June retains the right to confidentiality; yet unless she has signed a non-disclosure agreement that restricts circulation of her records to other healthcare institutions or third parties, the protection of her legal identity may be superseded in a case of emergency — entering the agency of her parents and the physician responsible for her well-being.

Patient Competency and Third-Party Decision-Making

Relevant elements of the Patient Bill of Rights in June's care include: (1) the right to safe, considerate, and respectful care, provided in a manner consistent with the patient's beliefs; (2) the right to expect that all communications and records pertaining to patient care will be treated as confidential to the extent permitted by law; (3) the right to know the physician responsible for coordinating patient care; (4) the right to receive complete information about diagnosis, treatment, and prognosis from the physician in terms that are easily understood; (5) if it is medically inadvisable to provide such information directly, it will be given to a legally authorized representative; (6) the right to receive all information necessary to give informed consent prior to any procedure or treatment, including a description of the procedure, potential risks or benefits, probable duration of any incapacitation, and available alternatives; and (7) exceptions will be made in the case of an emergency.

If June is deemed unable to make a reasonable decision to decline intervention — given that prior consent was provided while she was cogent — licensed medical staff who are part of the treatment team are most likely protected from malpractice by professional immunity. Reinsertion of the feeding tube by medical staff would be supported by the emergency rule, particularly where it becomes apparent that the physician must make a decision on behalf of the patient in response to her incompetent state of mind. The classification of anorexia as a mental health disorder is significant, because any forthcoming negligence accusation or tortious complaint such as battery should be dismissed, as the patient must be treated according to professional medical opinion rather than patient decision alone (Staunton and Chiarella, 2007).

Incapacitated patients may be represented in medical decisions by family members serving as interveners. In June's case, her mother and father insisted that the feeding tube be inserted despite her refusal. Her ex-husband wished to uphold June's decision. However, unless it is recorded in a prior court decision that he retains power of attorney — akin to his former status as spouse, an agent by custom and nature — he no longer has the authority to agree to or refuse treatment on her behalf (Showalter, 2008). An exception would apply if June had been placed under conservatorship in her ex-husband's care by court order. Regardless, consensus with her parents will further protect the institution from liability; a defense would be sustained if the patient were later to attempt to file a medical malpractice complaint, given that physicians and hospital administrators will seek legal counsel to guide June's care.

The Doctrine of Apparent Agency

The Doctrine of Apparent Agency, a rule element in commercial contract law, may be invoked within court decisions in some states. It allows for the separation and regulation of relationships between parties defined as: (1) agents and principals — for example, physician and parents versus the ex-husband; (2) agents and the third parties with whom they deal on their principals' behalf; and (3) principals and the third parties when the agents purport to act on their behalf (Showalter, 2008).