Saying “No” Is An Ethical Act
We’ve been having a lot of, shall I say, spirited discussions with patients’ families lately. Of course, we’ve always wanted our patients’ families to be informed about what’s happening with their children, our patients. Back in the bad old days, medical information was primarily relayed to non-clinicians by their own doctors and secondarily through evening newscasters reporting whatever JAMA headline their producer deemed most important for the public to know. The internet made the democratization of medical information a reality, as the public could now read JAMA articles for themselves (paywalls notwithstanding). Now, non-clinicians at least had access to the same information physicians did, so patients could, at least in abstract, have a more informed opinion in their care.
The term “shared decision-making” seems to have been coined in 1982, but its uptake by professional societies didn’t really happen until the 2000s (with it coming up reasonably frequently in guidelines by the 2010s). Until recently, however, even the practice of shared decision-making has, for me at least, still seemed somewhat one-sided. I tell a parent what’s happening with their child and what needs to be done to fix it. In critical care, there aren’t really a lot of decisions to be made: you do the thing that needs to be done to stop the dying. When there are decisions to be made, they’re pretty technical and don’t have a whole lot of value-laden components to them. When value-based decisions do need to be made, even that can feel one-sided, because so many of my patients’ parents’ values are “stop the dying, no matter the cost.” In my experience, most people only have a vague idea of what their values are until something holy unbelievable happens, typically at odds with what they thought their values were. When that occurs, people have to reconsider their values. And fast. Even as an ethicist, I haven’t received any formal training in helping people parse out their values, but here we are, helping families make value-based decisions, in sometimes the worst moments of their lives.
And then COVID happened. And the distrust some people already had for the medical system grew. And then more people came to distrust the medical system. And values that were previously abstract started to solidify. And the democratization of medical information came to social media, morphing into something different and unrecognizable to clinicians. And now we’ve been having a lot of spirited discussions with patients’ families.
Supplements and tinctures. Extracts and peptides. Ivermectin for everything. In your own practice, what have you been seeing? And where, if anywhere, are you drawing a line?
The reality is that telling a patient “no” is really, really hard. We (well, most of us, I imagine) came into medicine to serve others. And, either explicitly or implicitly, we recognize that the power differential between us and our patients puts them at a disadvantage, even with all the medical knowledge they have access to. The playing field is not level, no matter how big-hearted we are, or how highly intelligent we strive to be. So, telling a patient, “No, I’m not going to order what you’re asking for,” or “No, I will actively stand in the way of what you’re asking for,” is understandably, shall we say, uncomfortable.
But what if saying “no” is an ethical act? “Well, obvs,” you might say, “beneficence, nonmaleficence, autonomy, yadda, yadda, yadda…” Yes, and. Let’s unpack it a bit.
1. Ethically, “no” is not neglect. It’s moral discernment.
In medicine, we often equate “helping” with “doing.” But saying no can be an act of moral clarity. It’s a boundary that acknowledges the limits of beneficence and recognizes that not all interventions are ethically supportable just because they’re technically possible.
In this light, “saying no” may express:
Respect for non-maleficence — declining to act when doing so would cause harm.
Fidelity to justice — resisting inequitable or inappropriate use of limited resources.
Authenticity and integrity — refusing to violate one’s own moral compass.
A clinician who refuses a futile or harmful treatment isn’t being obstructive — they’re engaging in ethical stewardship.
2. Professionally, “no” protects the clinician as well as the patient.
For burned-out clinicians, especially women physicians, “saying no” is also an act of self-respect and moral preservation.
Moral injury often arises not from doing too little but from doing too much that feels wrong.
Saying no to:
one more committee that dilutes your focus,
one more shift that breaks your body,
one more task that someone else could do,
…is a way of aligning your actions with your values. In that sense, “no” becomes an ethical act of self-care — one that upholds the principle of autonomy in yourself, not just your patients.
3. Philosophically, “no” is what makes “yes” meaningful.
Ethics, at its core, is about choice under constraint. If everything is an automatic yes, there’s no moral agency at all. Saying no is what allows a clinician (or any human) to act intentionally. It’s the refusal that preserves the possibility of a genuine, value-aligned “yes.”
To know what we desire — ethically, clinically, humanly — we have to be willing to withhold, not just to give.
There is certainly a time and place when the balance of shared decision-making can shift in favor of the patient. A fully autonomous agent with unquestionable capacity saying, “Doc, I hear you, but your plan doesn’t sound good to me, I’m going to go a different way.” A patient with a terminal illness advocating for “one last shot” that includes your care and also a peptide infusion procured from and administered by somebody other than you. In gray areas, though, saying “no” is an ethical act, both a clinical truth and a moral survival strategy.
It reframes refusal not as failure or abandonment, but as an act of fidelity — to the patient’s good, to justice, and to one’s own integrity.
What will you start saying “no” to today?