PHI 204 - The Patient-Doctor RelationshipPresentation Transcript
The Patient-Doctor Relationship (Biomedical Ethics) Charles Lohman
Informed Consent The 2 Components
INFORMED CONSENT – a practical application of the principle of respect for patient AUTONOMY
The 2 components:
1.) DOCTOR’S DISCLOSURE
DOCTOR’S DISCLOSURE of medical information to the patient includes diagnosis, prognosis, available, and alternative treatments, and the risks, benefits, and consequences of having or refusing treatment.
2.) COMPETENT PATIENT
The COMPETENT PATIENT can decide whether to accept or refuse treatment on the basis of the DOCTOR’S DISCLOSURE.
The COMPETENT PATIENT is one who understands the nature of their condition and the consequences of accepting or refusing an intervention for their condition.
Informed Consent Beneficence -v- Autonomy
If the patient is a COMPETENT PATIENT
A patient’s AUTONOMY outweighs a doctor’s duty of BENEFICENCE.
A patient’s AUTONOMY is consistent with the doctor’s duty of NON-MALEFICENCE.
If the patient is NOT a COMPETENT PATIENT
Some say use a SLIDING SCALE
They say the required level of COMPETENCE should be on a SLIDING SCALE from low to high risk.
A physician’s PATERNALISM can outweigh a patient’s AUTONOMY and an intervention can be JUSTIFIED.
Some say MINIMAL COMPETENCE
They say a patient with MINIMAL COMPETENCE is enough for a patient to accept or refuse treatment.
Informed Consent Designated Surrogate
For a patient that is NOT COMPETENT, a designated SURROGATE can decide on the patient’s behalf.
A SURROGATE can act in 2 ways.
1.) The SURROGATE can make decisions about treatment as the patient would make if he/she were COMPETENT, thus exercising substituted judgment.
2.) The SURROGATE can decide on a course of action that he/she believes is in the PATIENT’S best INTEREST.
Informed Consent Advance Directive
A patient’s INTERESTS can be expressed in an ADVANCE DIRECTIVE
For example, a living will allows an AUTONOMOUS patient to extend AUTONOMY to a time when he/she is no longer COMPETENT to make decisions.
ADVANCE DIRECTIVE can serve 2 goals.
1.) It can express what the PATIENT would want doctors to do or not do.
2.) It can designate an individual to makes decisions for the PATIENT.
Informed Consent Parents -v- Child
IN GENERAL, parents can make decisions about their children’s TREATMENT because they are the best JUDGES of their children’s best INTERESTS.
A parental refusal of an intervention should be respected.
BUT the parents DECISIONAL AUTHORITY can be overridden if it causes direct and serious harm to the child.
MATURE MINOR can exercise personal AUTONOMY as long as they are not overly influenced or coerced by his/her parents.
INFORMATIVE model - The patient applies personal VALUES to determine which TREATMENTS to ACCEPT or REFUSE.
PATERNALISTIC model - The physician completely determines what is in the patient’s best INTEREST independent of the patient’s VALUES.
INTERPRETIVE model - The physician chooses a medical intervention that best fits the patient’s VALUES.
DELIBERATIVE model - The decision about treatment follows from SHARED deliberation between physician and patient.
THERAPEUTIC PRIVILEGE - a doctor can WITHHOLD medical information when it is potentially HARMFUL to a patient.
Two main objections
1.) Doctors can exaggerate or otherwise make mistakes in assessing the BENEFITS and HARMS of disclosure and nondisclosure.
2.) WITHHOLDING medical information fails to respect the patient’s AUTONOMY and fails to fulfill the doctor’s DUTIES of HONESTY and FIDELITY.
CONFIDENTIALITY - a doctor discloses medical information about a patient to the patient alone.
The duty to inform can override the duty to uphold CONFIDENTIALITY in specific instances.
Two arguments supporting physician’s obligation to uphold CONFIDENTIALITY with their patients.
1.) Respect for the patient’s AUTONOMY and PRIVACY
2.) Keeping TRUST between doctor and patient
The meanings Western doctors and non-Western patients attach to terms may be reflections of DIFFERENT belief systems.
This can be accommodated within a broad Western model of INFORMED CONSENT.
Example, NONMALEFICENCE and BENEFICENCE
Explaining the reasons for treatment(s) in culturally different terms is an alternative way to adhere to the duties of NONMALEFICENCE and BENEFICENCE.
In some cultures, it may be common for a competent adult to freely delegate DECISIONAL AUTHORITY to another adult. Although this differs from the Western liberal understanding of INDIVIDUAL AUTONOMY and INFORMED CONSENT, it can be interpreted as a different expression of AUTONOMY and CONSENT.