PHI 204 - The Patient-Doctor Relationship


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PHI 204 - The Patient-Doctor Relationship

  1. 1. The Patient-Doctor Relationship (Biomedical Ethics) Charles Lohman
  2. 2. Informed Consent The 2 Components <ul><li>INFORMED CONSENT – a practical application of the principle of respect for patient AUTONOMY </li></ul><ul><ul><li>The 2 components: </li></ul></ul><ul><ul><ul><li>1.) DOCTOR’S DISCLOSURE </li></ul></ul></ul><ul><ul><ul><ul><li>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. </li></ul></ul></ul></ul><ul><ul><ul><li>2.) COMPETENT PATIENT </li></ul></ul></ul><ul><ul><ul><ul><li>The COMPETENT PATIENT can decide whether to accept or refuse treatment on the basis of the DOCTOR’S DISCLOSURE. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The COMPETENT PATIENT is one who understands the nature of their condition and the consequences of accepting or refusing an intervention for their condition. </li></ul></ul></ul></ul></ul>
  3. 3. Informed Consent Beneficence -v- Autonomy <ul><li>If the patient is a COMPETENT PATIENT </li></ul><ul><ul><li>A patient’s AUTONOMY outweighs a doctor’s duty of BENEFICENCE. </li></ul></ul><ul><ul><li>A patient’s AUTONOMY is consistent with the doctor’s duty of NON-MALEFICENCE. </li></ul></ul><ul><li>If the patient is NOT a COMPETENT PATIENT </li></ul><ul><ul><li>Some say use a SLIDING SCALE </li></ul></ul><ul><ul><ul><li>They say the required level of COMPETENCE should be on a SLIDING SCALE from low to high risk. </li></ul></ul></ul><ul><ul><ul><ul><li>A physician’s PATERNALISM can outweigh a patient’s AUTONOMY and an intervention can be JUSTIFIED. </li></ul></ul></ul></ul><ul><ul><li>Some say MINIMAL COMPETENCE </li></ul></ul><ul><ul><ul><li>They say a patient with MINIMAL COMPETENCE is enough for a patient to accept or refuse treatment. </li></ul></ul></ul>
  4. 4. Informed Consent Designated Surrogate <ul><li>For a patient that is NOT COMPETENT, a designated SURROGATE can decide on the patient’s behalf. </li></ul><ul><ul><li>A SURROGATE can act in 2 ways. </li></ul></ul><ul><ul><ul><li>1.) The SURROGATE can make decisions about treatment as the patient would make if he/she were COMPETENT, thus exercising substituted judgment. </li></ul></ul></ul><ul><ul><ul><li>2.) The SURROGATE can decide on a course of action that he/she believes is in the PATIENT’S best INTEREST. </li></ul></ul></ul>
  5. 5. Informed Consent Advance Directive <ul><li>A patient’s INTERESTS can be expressed in an ADVANCE DIRECTIVE </li></ul><ul><ul><li>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. </li></ul></ul><ul><li>ADVANCE DIRECTIVE can serve 2 goals. </li></ul><ul><ul><li>1.) It can express what the PATIENT would want doctors to do or not do. </li></ul></ul><ul><ul><li>2.) It can designate an individual to makes decisions for the PATIENT. </li></ul></ul>
  6. 6. Informed Consent Parents -v- Child <ul><li>IN GENERAL, parents can make decisions about their children’s TREATMENT because they are the best JUDGES of their children’s best INTERESTS. </li></ul><ul><ul><li>A parental refusal of an intervention should be respected. </li></ul></ul><ul><ul><ul><li>BUT the parents DECISIONAL AUTHORITY can be overridden if it causes direct and serious harm to the child. </li></ul></ul></ul><ul><ul><li>MATURE MINOR can exercise personal AUTONOMY as long as they are not overly influenced or coerced by his/her parents. </li></ul></ul>
  7. 7. Informed Consent Patient-Physician Relationship Models <ul><li>INFORMATIVE model - The patient applies personal VALUES to determine which TREATMENTS to ACCEPT or REFUSE. </li></ul><ul><li>PATERNALISTIC model - The physician completely determines what is in the patient’s best INTEREST independent of the patient’s VALUES. </li></ul><ul><li>INTERPRETIVE model - The physician chooses a medical intervention that best fits the patient’s VALUES. </li></ul><ul><li>DELIBERATIVE model - The decision about treatment follows from SHARED deliberation between physician and patient. </li></ul>
  8. 8. Therapeutic Privilege <ul><li>THERAPEUTIC PRIVILEGE - a doctor can WITHHOLD medical information when it is potentially HARMFUL to a patient. </li></ul><ul><li>Two main objections </li></ul><ul><ul><li>1.) Doctors can exaggerate or otherwise make mistakes in assessing the BENEFITS and HARMS of disclosure and nondisclosure. </li></ul></ul><ul><ul><li>2.) WITHHOLDING medical information fails to respect the patient’s AUTONOMY and fails to fulfill the doctor’s DUTIES of HONESTY and FIDELITY. </li></ul></ul>
  9. 9. Confidentiality <ul><li>CONFIDENTIALITY - a doctor discloses medical information about a patient to the patient alone. </li></ul><ul><ul><li>The duty to inform can override the duty to uphold CONFIDENTIALITY in specific instances. </li></ul></ul><ul><li>Two arguments supporting physician’s obligation to uphold CONFIDENTIALITY with their patients. </li></ul><ul><ul><li>1.) Respect for the patient’s AUTONOMY and PRIVACY </li></ul></ul><ul><ul><li>2.) Keeping TRUST between doctor and patient </li></ul></ul>
  10. 10. Cross-Cultural Relations <ul><li>The meanings Western doctors and non-Western patients attach to terms may be reflections of DIFFERENT belief systems. </li></ul><ul><ul><li>This can be accommodated within a broad Western model of INFORMED CONSENT. </li></ul></ul><ul><ul><ul><li>Example, NONMALEFICENCE and BENEFICENCE </li></ul></ul></ul><ul><ul><ul><ul><li>Explaining the reasons for treatment(s) in culturally different terms is an alternative way to adhere to the duties of NONMALEFICENCE and BENEFICENCE. </li></ul></ul></ul></ul><ul><ul><ul><li>Example, Autonomy </li></ul></ul></ul><ul><ul><ul><ul><li>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. </li></ul></ul></ul></ul>