Chapter Seven Autonomy vs. Paternalism: A Contest Between Virtues
“Who Is The Patient?” Consider the “Who Is the Patient” case that begins the chapter Should the physician write the prescription? What system (duty, consequence, virtue, divine command reasoning) did you use to make the decision? What basic principles did you consider?
The Case for Paternalism Acting in a way believed to protect and advance the interests of another, although actions may be against the other’s desires We have more information than the patient (trust me, I’m a doctor!) They came to us to help them No one rational chooses bad health
Paternalism Historically, health care has moved from paternalism toward patient autonomy Paternalism does not necessarily equal abusive power. In its best sense it is a conflict between two basic principles: Autonomy Beneficence
Health – the Universal Good Health is often considered a universal good. It is, however, not always our highest priority. If health were our priority, following good health care advice would always be the best policy.
Health – the Universal Good (continued) Health care decisions are not only matters of medical expertise but also of individual value preference
Autonomy vs. Paternalism Professional autonomy. Does patient’s desire for less than optimal care trump practitioner’s desire to provide the best care possible? Can practitioner refuse to treat a non-compliant patient? Problem of abandonment.
Proposed Provider-Patient Relationship Models Which of these models best fits the current patient-provider relationship? Engineering Priest Collegial Contractual
Informed Consent Essential elements: Disclosure Understanding Voluntariness Competence Consent Does autonomy include a right not to know?
Informed Consent (continued) Consent can take many forms: Oral Written General Special Implied
Evolution of Disclosure Standards Disclosure standards: Professional community standard Reasonable patient standard Patient-centered standard Which is the current legal standard? Which is perhaps the most ethical standard?
Competency Determination Does the patient understand the nature of the illness, and the consequences of the various options that may be chosen? Is the decision based on rational reasoning or protected under First Amendment?
Competency Determination (continued) Competent adults have an absolute right to refuse medical treatment even if the refusal is life-threatening
Autonomy vs. Paternalism (case problem) A pregnant female is brought to the emergency room, bleeding profusely, needing a transfusion to save her life and that of the fetus A Jehovah’s Witness, she refuses the transfusion Does she also speak for the fetus? Is there a limit to her autonomy?
Protection of Children The courts have generally held: Parents may refuse care for themselves for religious beliefs They may not make choice for children Prior to the age of full and legal discretion, neither parents nor the child make the choice Guardian ad litem
Demand for Futile Care Helga Wangele and Baby K: In both cases, the courts held that care beyond palliative measures should be provided, even in situations that health providers deemed to be futile Is this equal to the oft heard “The customer is always right”?
Emergency Medical Treatment and Labor Act (EMTALA) Hospitals must: Provide medical screening for all patients who seek emergency care Stabilize patient’s condition Maintain an accurate on-call physician directory Provide medically appropriate transfers
APACHE Scoring System Review Exercise F in review exercises Do these evaluation systems provide an answer to the request for futile care conflicts? Would you find the current level of accuracy acceptable? If not, what level would you demand?
Autonomy Reconsidered Have we moved too far in support of autonomy? The demand for futile care? The right of pregnant women to refuse AIDS testing? The right for mentally incompetent homeless to stay on the streets in inclement weather?
Key Concepts Modern health care has moved away from the principle of paternalism and toward honoring patient autonomy Competent adult patients are accorded the right to make the significant decision in regard to their personal health care
Key Concepts (continued) Competent adults have the right to refuse medical treatments, even in life-threatening situations
Key Concepts (continued) Competency is granted following the affirmation of the following: Patient understands nature of illness and consequences of options available Decision is based on rational reasoning If decision based on faith, is it entitled to First Amendment protection under the Constitution?
Key Concepts (continued) Demand for futile care: The courts have in general found for the patient and family in cases where the disagreement seems to be a matter of health provider-patient value differences in goal outcomes Helga Wangele case Baby K case