Background: Approximately 26% of hospitalized patients and 44% of nursing home residents lack the capacity to make key medical decisions (1). When this occurs, clinicians turn to surrogates to make decisions on behalf of the patient. Sometimes the incapacitated patient will verbally or physically object to the surrogate’s decision, despite the surrogate sincerely believing the decision is in the patient’s interest. In situations like this, clinicians and surrogates must assess if they should respect the patient’s incapacitated refusal or override the patient’s objection and proceed with treatment. Although national data are lacking, one academic medical center reported 35 ethics consults about this specific issue over a three-year period (2). This Fast Fact explores the ethics of treatment over objection (TOO).

Case review: Three cases illustrate the variety of ways clinicians may encounter TOO decisions.  

1. An 85-year-old patient is admitted with peritonitis due to perforated appendicitis and develops hospital-acquired delirium. She persistently asks to be left alone, refusing emergency appendectomy, which her surrogate firmly believes she would consent to if she was not delirious. Should the team proceed with surgery over the patient’s request to be left alone?
2. An unhoused patient with schizophrenia and widely metastatic cancer who has lost 50 lbs. and missed multiple oncology visits suffers from headaches and vision changes. He persistently refuses to allow a brain MRI because he believes that he does not have cancer. Should the medical team sedate the patient and obtain the MRI for staging and prognostication?
3. A patient with advanced kidney disease is admitted with flash pulmonary edema and renal failure; he refuses dialysis, believing that his body will heal itself with vitamins, despite the medical team’s best counseling. Should the team sedate him to place a dialysis catheter and perform regular dialysis?

Ethics of treatment over objection (TOO): Medical ethics requires clinicians to balance multiple principles in these cases: autonomy—an informed patient’s right to make their own medical decisions, beneficence—doing what benefits the patient, non-maleficence—avoiding harm to the patient, and respect for persons—what is appropriate and respectful for one person to impose on another. Patients who lose decision-making capacity lack the ability to exercise their autonomy, and therefore clinicians and surrogates focus on beneficence, non-maleficence, and respect for persons. When incapacitated patients object to treatment that clinicians or surrogates feel will improve their quality or quantity of life, clinicians and surrogates must consider how the objection coheres with the patient’s values and how the patient might decide if they had capacity (substituted judgment). Finally, they must consider how overriding the patient’s objections impacts the patient’s well-being and dignity (3).

Recommend steps for clinicians and surrogates when TOO is being considered: 

1. Begin by seeing if the patient’s objection can be ameliorated. Rather than overriding the incapacitated patient, clinicians may be able to resolve the conflict through negotiation or compromise. In the second case, for example, the patient may be willing to undergo a brain MRI if the team focuses on how the MRI may help treat his headaches, rather than the diagnostic information it gives about his malignancy. In the third case, the patient may be willing to undergo dialysis if the team agrees to simultaneously provide him with the requested vitamins.
2. Incorporate the prognosis and clinical urgency into their decision-making. An emergency life-saving intervention is very different from an elective or high-risk surgery in a patient with a short life expectancy. Honest discussions about the patient’s prognosis—both in terms of morbidity and mortality—with and without the medical treatment is crucial. Decision-making aids like “Best Case/Worst Case” may be helpful (see Fast Fact #486). In the first case, emergency appendectomy would likely be lifesaving, while in the second case, the MRI is less likely to change his prognosis.
3. Consider the logistics and timing involved with overriding the patient’s objection. A one-time intervention (e.g., surgery in the first case) is different from a lengthy or recurrent one (e.g., three times a week hemodialysis). Treatments which require ongoing patient cooperation (e.g., hyperfractionated radiation) are difficult to implement. Sometimes the intervention itself may allow the patient to regain capacity (e.g., a reversible delirium from uremia). In the second case, the patient is unlikely to ever participate in chemotherapy and forcing him to do the MRI may be less beneficial.
4. Consider how the patient may be affected emotionally and physically by forced intervention. Forcible treatment may erode the patient’s trust in their healthcare clinicians, contribute to healthcare trauma, and decrease willingness to participate in other treatments.

Resolving conflict: Engagement in the 5 questions below, derived from a clinical ethics decision tool, may help medical teams and surrogates make better decisions in these challenging situations (4):  

1. Why might this patient be refusing this medical intervention?
2. What is the severity of harm with and without the proposed intervention? How imminent is that harm?
3. What is the anticipated efficacy of the intervention?
4. What would be the logistics of TOO?
5. What would be the emotional effect of forced treatment on the patient?

Interdisciplinary support: Cases of TOO often benefit from an interdisciplinary approach. Bedside nurses have frequent patient touchpoints allowing for valuable input of the trajectory of the patient’s capacity and care preferences. Social workers may uncover unappreciated psycho-social reasons for the patient’s refusal. Chaplains may identify additional sources of distress and support. Palliative care or ethics consultation may assist with communication, goals of care clarification, and delineating hospital policies and procedures.

References: 

1. Sessums LL, Zembrzuska H, Jackson JL. Does this patient have medical decision-making capacity?. JAMA. 2011;306(4):420-427. doi:10.1001/jama.2011.1023.
2. Fischkoff D, Prager K, Dastidar J, et al. Ethical Framework to Guide Decisions of Treatment Over Objection. J Am Coll Surg. 2021;233(4):508-516.e1. doi:10.1016/j.jamcollsurg.2021.07.003.
3. Navin MC, Wasserman JA, Haimann MH. Treatment Over Objection-Moral Reasons for Reluctance. Mayo Clin Proc. 2019;94(10):1936-1938. doi:10.1016/j.mayocp.2019.08.011.
4. Rubin J, Prager KM. Guide to Considering Nonpsychiatric Medical Intervention Over Objection for the Patient Without Decisional Capacity. Mayo Clin Proc. 2018;93(7):826-829. doi:10.1016/j.mayocp.2018.04.005.

Authors’ Affiliations: Icahn School of Medicine at Mount Sinai, New York, NY.
Conflicts of Interest: Dr. Gross has no conflicts of interest. Dr. Arnold serves on the board of VitalTalk.
Version History: First electronically published in March 2026, originally edited by Sean Marks MD.