Ordinary and Extraordinary Treatment

Every person with decisional capacity has the right to refuse any treatment, regardless of the nature of the treatment or consequences of the refusal. The surrogate decision-making has the power to act on this right for the patient, as long as there is reason to believe that the surrogate is making decisions based on the patient’s wishes, values, or interests.

That said, some people and groups believe that some refusals of treatment are acceptable and not others. They argue that it is morally worse to refuse “ordinary treatment” rather than “extraordinary treatment.” This was based on the idea that people have a general obligation to act to sustain their own lives. A certain degree of pain and suffering is normal. To refuse to do the basic minimum to sustain one’s life is morally wrong because it undermines life itself, much like suicide.

Lately, insurance providers have used the ordinary/extraordinary distinction to determine which treatments they need to cover and which do not constitute “basic care.”

The key to both of these arguments is the focus on categorizing types of treatment. The error (on their own terms) comes when it is not acknowledged that what is ordinary for one patient may be extraordinary for another. Legally no distinction between treatment in categories is recognized with regard to the right to refuse treatment. However, some see a moral difference and refusal of ordinary treatment may be a sign that a surrogate is not acting in good faith.

Ordinary and extraordinary treatment are generally categorized as follows:

Ordinary Treatment -

  1. Low risk of harm.
  2. Simple, relatively low tech.
  3. Routine.
  4. Good chance for benefit to the patient.
  5. Relatively inexpensive.
  6. Available to most people who need it.
  7. Causes little pain or distress.

Extraordinary Treatment -

  1. High Risk
  2. Complex, relatively high tech.
  3. Innovative, experimental, unusual.
  4. Relatively small chance for benefit to the patient.
  5. Relatively expensive.
  6. Available to few (may involve distributive justice issues).
  7. Usually a source of pain or distress.

Any treatment is extraordinary if the burdens outweigh the benefits or it offers no hope of benefit for the patient. (Purtilo, R. Ethical Dimensions in the Health Professions (Saunders, 1999) p220.) But who defines benefit and burden? And what meets the criteria of hope?