We thank Hayes et al.1 for their thoughtful engagement with our editorial2 and for reaffirming the central importance of consent and shared decision-making in the Goals of Care (GOC) process. We agree unequivocally that a patient with decision-making capacity has the right to refuse treatment and that any form of coercion during the consent process invalidates that consent. Respect for patient autonomy remains a foundational principle in the shared decision-making model of medicine. Our editorial2 was not intended to challenge these principles, but rather to highlight the broader structural context in which GOC discussions often occur in Australia, particularly the absence of consistent national guidance governing these conversations and the potential harms arising from variability in practice. Hayes et al. raise the concern of coercion in the case presented.1 We agree that this issue warrants careful consideration. However, a review of Australian case law suggests that explicit judicial findings of coerced consent are extremely rare. Explicit judicial findings that a doctor coerced consent, that is, held the clinician deliberately used improper pressure, are all but absent in reported decisions. Courts more commonly determine that there was no legally effective consent: on the basis of lack of informed consent, trespass to the person or procedures exceeding the scope of consent.3-5 While elements of coercion may plausibly have been present in the case described,2 the broader issue may lie in the inherent power imbalance between clinicians and patients, particularly in high-stakes clinical settings. In our view, addressing this imbalance requires not only education regarding consent and shared decision-making but also the provision of structured guidelines that clearly delineate the essential elements of the consent process, including both required and unacceptable practices. This is especially important in critical care, where decisions often occur under conditions of uncertainty and the potential for serious morbidity or death. Accordingly, rather than focussing solely on the difficult question of whether coercion occurred in a specific interaction, our editorial sought to highlight a complementary issue: the absence of a consistent, structured national framework to guide GOC discussions in high-stakes clinical settings. As described in the case vignette,2 the distress arose not from a failure to disclose material risks, but from repeated, fragmented conversations that became counterproductive and burdensome. The question was not whether the patient had the right to refuse treatment, she clearly did, but how clinical systems can avoid repetitive or siloed conversations that risk undermining trust, dignity and autonomy, all of which are pivotal to shared decision-making. We concur that ongoing education regarding consent and shared decision-making remains essential. At the same time, we maintain that structural reform is also required. A national, purpose-built framework for GOC discussions could help operationalise existing ethical principles by promoting timely, coordinated and team-based GOC conversations. Such an approach may better safeguard patient autonomy while reducing unnecessary duplication, confusion and moral distress for both patients and clinicians. We appreciate the opportunity to clarify our position further and welcome continued dialogue on strengthening both the ethical and structural foundations underpinning the GOC practice in Australia. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Michel et al. (Wed,) studied this question.