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Doctors have a legal duty to ensure that their patients have sufficient information and understanding to make informed choices about proposed treatment. But what can and should they do if a patient whose competence to make such a decision is in doubt refuses much needed treatment? Here a general practitioner describes a tragic situation that arose with a schizophrenic patient, and a lecturer in general practice, a Church of England ordinand, and a general practitioner make their observations.# Best of motives, worst of consequences {#article-title-2}My patient was a 62 year man who was looked after by his mother. He was a “burnt out” schizophrenic of low intelligence and used to spend most of his time on long walks on his own. He was always hyperactive and communicated with staccato speech, but he was always pleasant and reasonably well presented. My patient's mother died two years ago, and he had become increasingly dirty and unkempt. He walked the streets daily and found it difficult to keep still. He continued to come to the surgery regularly for his medication, and we noticed that the chair he sat on in the waiting room was faecally soiled and he began to smell.We alerted social services to the change. They visited the man at home, where he now lived on his own. His home was in an appalling state, with faeces everywhere, and he was overtly faecally incontinent. He consented to a physical examination and was found to have a severe rectal prolapse. He did not seem overly concerned about his incontinence and his general state.The patient was referred to a consultant surgeon and was told he needed an operation to correct the prolapse. He refused to proceed—he would not accept that there was a problem. The situation deteriorated and his home became uninhabitable. Social services arranged for it … Correspondence to: Dr Julia Hippisley-Cox

bmj. british medical journal

Ethical dilemma: Competency, consent, and the duty of care Best of motives, worst of consequences Let the courts decide The only failure was the outcome