Mr. Warren has come to see his doctor about recurring chest pain. An X-ray shows a suspicious mass, and Dr. Webb recommends a biopsy. Mr. Warren says he has no interest in taking any tests, since he believes that regardless of the diagnosis he will be cured through prayer.

How should Dr. Webb respond? She has developed great respect for Mr. Warren over the years and does not want to coerce him into a decision against his will. However, she is also concerned that he may face a terminal condition that could be treated and possibly cured if identified soon.

If Mr. Warren had agreed to testing, the doctrine of informed consent would require that he be adequately informed, possess decision-making capacity, and that he act voluntarily. Less frequently discussed, but of equal importance, is the doctrine of informed refusal, for which the same three elements are crucial.

Mr. Warren has the right to refuse diagnostic testing on religious grounds. However, in the same way that consent lacks meaning if a patient has not been adequately informed, Mr. Warren cannot make an informed refusal without certain facts. There is no exact formula for this process, but adequate information would certainly include the risks and benefits of tests Dr. Webb recommends, hazards and advantages of alternative tests, and the burdens and benefits of forgoing all diagnostic procedures.

A patient's decision-making capacity is also important. If Mr. Warren understands the information provided about the biopsy and other tests, can weigh the burdens and benefits within the context of his own world view, and can make and communicate his decision, he has decision-making capacity, even if his decision is not one most patients would make or his physician recommends.

Dr. Webb may be concerned that by providing Mr. Warren with information about the risks of not obtaining a diagnosis, she is being coercive and insensitive to his religious beliefs. Certainly she shouldn't browbeats her patient with dark predictions about the risk he is taking. However, there are a number of ways she can avoid that scenario:

First, she should reassure him that he will not be abandoned. Second, she should remember that her bearing, words, and actions communicate whether or not she respects her patient. Third, Dr. Webb should explain to Mr. Warren that she is obliged to provide him with information about the tests, and that she would like for him to think it over before he decides. Dr. Webb should record their conversation and Mr. Warren's decision in the medical record.

Respect for patients' religious beliefs need not conflict with the obligation to adequately inform them about the burdens and benefits of therapy.