Obligatory and optional treatments: proportionality
- Topic
A treatment is obligatory if its benefits outweigh its burdens for that patient; if not, it is optional and can be refused or not offered.
What it is
Moral tradition distinguished «ordinary» means, which had to be used, from «extraordinary» means, which could be refused. The distinction misleads if it rests on technology (common versus sophisticated), because the same measure can be reasonable for one patient and a useless burden for another. Today the term is proportionality: a treatment is proportionate, and therefore obligatory to offer, when its expected benefits outweigh its burdens for that person; if not, it is disproportionate and optional. The team judges what the measure can achieve; the patient judges whether that result is worth it to them. The futility page covers resuscitation; this page covers the general rule, including requests for non-beneficial treatments.
Key facts
- Benefits that count: prolonging a life the patient values, relieving, recovering function or gaining time for a goal.
- Burdens that count: pain, risk, invasiveness, dependence, loss of consciousness, duration and cost to the patient and family.
- Who judges what: the team judges what the measure can achieve; the patient judges whether that result outweighs the burdens.
- Therapeutic obstinacy: insisting on disproportionate measures that prolong dying.
- Abandonment: the opposite error, withdrawing proportionate measures or ceasing to care.
- Faced with a request without benefit: listen to the reason, explain, offer a second opinion and, if disagreement persists, consult the ethics committee.
The same treatment, different balances
| Treatment | Proportionate when... | Disproportionate when... |
|---|---|---|
| Mechanical ventilation | Severe pneumonia in a previously healthy adult | Terminal neuromuscular disease and the patient has already refused it |
| Dialysis | Acute kidney failure with likely recovery | Great frailty, several advanced diseases and suffering at every session |
| Antibiotics | Treatable infection in a patient who values going on living | Pneumonia in the dying phase, when the agreed goal is comfort |
| Major surgery | Resectable tumour in good general condition | Prognosis of days and high risk of dying in the operating room |
In clinical practice
- Ask about goals before offering measures: «What matters most to you now?».
- If the family asks for a measure without an indication, explain what it can and cannot achieve, and what will still be done.
- Propose time-limited trials when the balance is uncertain.
- Record the proportionality reasoning, not just the decision.
Legal framework in Colombia
- Ley 23 de 1981, art. 10, parágrafo: the doctor will not demand unnecessary tests or subject the patient to treatments that are not justified.
- Ley 23 de 1981, art. 13: use the methods and medicines available while there is hope of relieving or curing; with a diagnosis of brain death there is no obligation to maintain other organs by artificial means.
- Resolución 813 de 2026, art. 14: every deliberation on adjusting therapeutic effort sets out the available options and points out what may be inappropriate, not indicated, unsupported by science or harmful; art. 15: if there is no medical consensus, the hospital ethics committee may be consulted.
- Resolución 813 de 2026, art. 24, par. 1: the reasonableness of treatments depends on proportionality, double effect and what the patient considers quality of life and dignity.
- Official texts checked on 2026-11-13 at minsalud.gov.co (Ley 23 de 1981 and Boletín Jurídico No. 04 de 2026, section 2.2.6).
Test yourself
Think of the answer, then tap the question to see it.
What makes a treatment ethically optional?
That for this patient its burdens (pain, risk, dependence, duration) outweigh the expected benefits: it is disproportionate and may be refused or not offered.
Why is it misleading to define «extraordinary» by technology?
Because the same measure, such as dialysis or an antibiotic, can be proportionate in one patient and disproportionate in another; the balance decides, not the technology.
What does article 13 of Ley 23 de 1981 say?
That the doctor uses the available methods and medicines while there is hope of relieving or curing, and that after brain death there is no obligation to maintain other organs artificially.
What is therapeutic obstinacy?
Insisting on disproportionate measures that only prolong dying; Resolución 813 de 2026 states that adjusting therapeutic effort aims to prevent it.
Connections
Educational content on ethics and health law; not legal advice. Laws and case law change: each page links the official text and says when it was last checked. For a real case, read the text in force and ask a lawyer or the medical ethics tribunal.
Sources: Ley 23 de 1981, por la cual se dictan normas en materia de ética médica (Ministerio de Salud y Protección Social, 1981); Boletín Jurídico No. 04 de 2026, sección 2.2.6: Resolución 813 de 2026 (Ministerio de Salud y Protección Social, 2026); WMA Declaration of Venice on End of Life Medical Care (World Medical Association, 2022).
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Representative model, for educational purposes only.