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This explanatory study examined the reasons why physicians have difficulty respecting the wishes of terminally ill patients who refuse treatment. Consistent with the relevant literature, three alternative explanations were hypothesized in answering the question: fear of litigation, religious beliefs, and medical professional values.
Evidence was gathered from three different sources. Semistructured interviews were carried out with 24 emergency physicians from the Moncton Area in the Canadian province of New Brunswick and submitted to both quantitative and qualitative content analysis. Nineteen cases of terminally ill patients whose wishes not to be treated were not respected were collected and submitted to content analysis. Finally, administrative policies on resuscitative policies and on clinical ethics committees of all New Brunswick Hospital Corporations were collected and also submitted to content analysis.
The results of the study showed that fear of litigation may be a partial explanation in about one third of the cases, but contradictory evidence also pointed to diverging conclusions. Religious beliefs may also account for certain physicians' attitudes toward refusal of treatment by their terminally ill patients. Statistically significant differences were found between unilingual and bilingual physicians. However, medical professional values were demonstrated to be the single most important factor in explaining why physicians acted the way they did in the treatment of their terminally ill patients. Normative pluralism and especially Luhmann's self-reference concept may explain why physicians had so much difficulty adapting their behaviors to meet the courts' legal decisions and the legislative changes respecting the rights of terminally ill patients who refuse treatment.