class on bio ethics

1. BIOETHICS- PATIENT
AUTONOMY AND
DECISION MAKING
DrY. N. Singha
Associate Professor & I/C
Department of Forensic Medicine
Silchar Medical College

2. INTRODUCTION
What is Autonomy ?
The freedom and ability to act in a self-determined
manner
An integral part of patient autonomy is the ability
to make decisions over bodily integrity
Depends on the patient being given the
information in a manner that they understand

3. AUTONOMY
Informed consent
Effective medical treatment - a mutual (bilateral)
communication between a doctor and a patient
Increases patient's legal and health awareness
Represents a patient's consent to a medical
treatment on the basis of previous instruction
Required in addition for the health care to be
provided

4. AUTONOMY
Elements and requirements of the Informed
Consent
A valid consent is composed out of 3 segments,
that need to be present all at a time
Given by a competent person
A person has to be overly informed about the
whole procedure or process to which he is giving
his consent
Needs to be given voluntarily, not under any kind
of pressure

5. AUTONOMY
EXCEPTIONS CONCERNING INFORMED
CONSENT
In case of their appearance in a particular
situation override the right to self-determination,
and a doctor's act is allowed even without
obtaining consent to a treatment
1) Emergency Exception
2) Incompetence
3) A Right to Not Know and Therapeutic Privilege of
Doctor
4) Compulsory Treatment

6. AUTONOMY
The Convention on Human Rights and
Biomedicine
“An intervention in the health field may only be
carried out after the person concerned has given
free and informed consent to it. This person shall
beforehand be given appropriate information as
to the purpose and nature of the intervention as
well as on its consequences and risks. The person
concerned may freely withdraw consent at any
time." (Article 5)

7. THE PRINCIPLE OF AUTONOMY
One of the basic principles accepted worldwide
Contains :
1. a protection of autonomous decisions
2. a protection of bodily integrity
Consists of more partial rights:
1. the right of patient to know all the information
about a treatment
2. the right to make decisions about treatment

8. THE PRINCIPLE OF AUTONOMY
The right to not be treated without one's consent
to it
The right to either consent or refuse the proposed
treatment
If a consent to a treatment is given, a particular
treatment (intervention) can be done. However,
there is a possibility to withdraw such consent at
any time

9. THE PRINCIPLE OF AUTONOMY
The treating Physician must do everything
possible to ensure that patients (or their
representatives in case of incompetence)
understand all issues related to their clinical
status
Inform them of the possible courses of
therapeutic action available to them and make
sure that they are acting of their own volition and
not under any external duress
If so, patients are considered to be autonomous,
and by extension competent to make decisions
related to their bodies or health, and it is the
practitioners’ duty to accept and respect their

10. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Decisional Autonomy
Functional Autonomy
Executive Autonomy
Narrative Autonomy
Informative Autonomy

11. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Decisional Autonomy
Refers to patients’ freedom of choice, in other
words, their capacity to deliberate and decide on a
course of action from among a suitable range of
useful options
Exercised between the medical practitioner and
the patient

12. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Functional Autonomy
 Patients’ capacity to perform the basic activities
of daily living and to individually undertake tasks
that a statistical majority of people normally
perform (such as eating, seeing, walking,
understanding complex situations, etc.)
Depends upon the Mental, Physical and Sensory
functions

13. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Functional Autonomy
 Contributed by the disabilities people have and
also from disabling environments
Relates to the material possibility of performing a
task (e.g., getting dressed without help)

14. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Executive Autonomy
May be defined as the capacity to implement the
decision made and maintain it over time, in other
words, to execute it
Involves the patient’s capacity to plan, sequence,
and perform tasks related to the management of
their chronic disease, especially those related to
the planning and execution of treatment

15. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Executive Autonomy
The patient’s executive autonomy is essential for
effective supervising and executing the treatment
plan
The essential aspect is the ability to keep to the
course of action decided upon (e.g., quitting
smoking)
Non-adherence, ignoring or underrating the
importance of executive autonomy leads to
“poorer health outcomes for patients, repeated
hospitalizations, and frustrated clinicians”

16. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Narrative Autonomy
The capacity that patients have to retain,
understand, and communicate for others, related
to circumstances of their illness, management
and treatment they received
Being capable of participating in certain types of
communicative interactions with others
Is the most basic features of the reality shared by
patient and audience

17. THE FIVE DIMENSIONS OF
PATIENT AUTONOMY
Informative Autonomy
Involves patients’ ability to access and control
their personal, intimate, private, and public
information
Informative autonomy covers, the personal
management of clinical information, the right to
communicate or protect such information, the
doctor’s duty of confidentiality, and the skills
required to communicate with others about the
condition

18. AUTONOMIES IN
INTERACTION
In these theories, the central aspect is individuals’
mental state, their transitory or permanent
capacity to take responsibility for their actions.
Some patients enjoy only limited functional
autonomy yet are decisional, executively, or
narratively autonomous
In other cases, poor executive autonomy may be
found with no other significant autonomous
deficit

19. AUTONOMIES IN
INTERACTION

20. THE CASES APPROACH
Developed by the National Centre for Ethics in
Health Care
Clarify the facts & requirements
Assemble the relevant information
Synthesize the information
Explain the synthesis
Support the ethical decision making process

21. THE CASES APPROACH
Clarify the facts & requirements
Characterize the type of problem
Obtain information about the case
Establish the goal from the ethical analysis
(consultation process)
Formulate the ethics question

22. THE CASES APPROACH
Assemble the relevant information
Consider the appropriate sources of information
Gather information systematically from each source
Summarise the information and the ethics question

23. THE CASES APPROACH
Synthesize the information
Determine weather a formal meeting is needed
Engage in ethical analysis
Identify the ethically appropriate decision maker
Facilitate moral deliberation about ethically
justifiable options

24. THE CASES APPROACH
Explain the synthesis
Communicate the synthesis to key participant
Provide additional resources
Document the consultation in the health record
Document the consultation in service records

25. THE CASES APPROACH
Support the ethical decision making process
Follow up with the decision taken
Evaluate the outcome of the decision
Adjust the consultation process
Identify underlying systems issues

26. THE FOUR BOXES MODEL
MEDICAL
INDICATION
S
PATIENT
PREFERENCE
S
QUALITY OF
LIFE
CONTEXTUA
L FEATURES

27. THE FOUR BOXES MODEL
Medical Indications
Facts that indicate which form of diagnostic,
therapeutic or educational interventions are
appropriate
Is the problem Acute, chronic, critical, reversible
terminal ?
What are the goals of treatment ?

28. THE FOUR BOXES MODEL
Medical Indications
In what circumstances are the medical treatment
not indicated ?
What are the probabilities of success of various
treatment options ?
How can the patient be benefited by medical care ?
How can any form of harm be avoided ?

29. THE FOUR BOXES MODEL
Preferences of the patient
The choices that the patients make when they face
with the decisions about their health and medical
treatment
Consultant should include Ethical issues like :
Informed consent Refusal of treatment
Autonomy of the patient Advance directives
Alternative medicines Challenging patients
Cultural and religious beliefs

30. THE FOUR BOXES MODEL
Quality of life
Refers to that degree of satisfaction that people
experience and value about their lives as a whole
and in its particular aspects, such as physical health
The main ethical principles involved are :
Beneficence and Autonomy

31. THE FOUR BOXES MODEL
Quality of life
Relevant ethical questions :
What are the prospects with or without treatment
for return to normal life
What ethical issues may arise concerning
improving patients quality of life

32. THE FOUR BOXES MODEL
Contextual features
It addresses the ways in which professional,
familial, religious, financial, legal and institutional
factors that may influence clinical decisions
Involved ethical principles includes - respect for
patient autonomy and justice
Justice refers to those moral and social theories that
attempt to distribute the benefits and burdens of a
social system in a fair and equitable way among all
participants in the system

33. CONCLUSION
Autonomy entails considerably more than just
decision-making by the patient and respecting that
autonomy involves much more than simply
presenting an informed consent form for signing
An important deficit in a person’s mental capacity
will result in a diminishment of both their
decisional and functional autonomy
People’s mental capacity is the link between
decisional and functional autonomy
In cases of serious mental damage, no other
dimension of autonomy is possible

34. CONCLUSION
Patients with very severe mental impairments are
not capable of :
Making decisions (decisional autonomy)
Performing for themselves many tasks that majority
of people can perform (functional autonomy)
Keeping to a given treatment over time (executive
autonomy)
Manifesting their communicative intentions in such
a way as to mold the response of their audience
(narrative autonomy)
Accessing and controlling their personal, intimate,
private, and public information