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PHL283 Jan 13 2011

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Jonathan Peterson

PHL283 Jan 13 th - what is the principle of autonomy? o governance – right to make your own decision – respect for their right - physician-patient relationship - paternalism Starson - in and out of mental institutions – suffers from bipolar disorder o mood shifts/wildly varying energy levels - suffers from serious delusions – believes he is a scientist etc. - trained in physics – cares about it - he has a history of making death threats against people o gets in trouble with the law o not criminally responsible for the threats on the basis of his condition  committed to an institution for 12 months - involuntarily - you believe – over time, his condition has been getting worse o without treatment, he will not get better and not be able to live a life outside an institution and function in a society - there is a new medication, and you have good reason to believe that it will help him lead a normal life o Starson’s response? – doesn’t want to take the medication – dulls his mind - cannot think clearly – stifles his creativity – no interest in taking the medication – sees no benefit - given the fact this person is mentally ill, why should his decision matter? - what should be done? - raises questions about the patient’s role in medical decision making o conflict between autonomy and other values  promoting the well being of the patient – obligation of heath care workers? - what happened? o the courts decided that since he understood that he was ill, and he understood what the results of refusing the medication will be, he was competent enough to make his own decision to refuse it 4 Models – Emanuel & Emanuel - 4 variables in which the models differ from each other o A. the goals/purposes of the physician-patient relationship o B. the duties/obligations of the physician o C. the role of the patient’s values o D. what’s the conception of autonomy that the 4 models offer and how do they differ 1. Paternalistic Model - “fatherly” or “parental” model where the doctor knows best - no longer the dominant model o A. promoting the patient’s well being and health o B. patient’s interests are paramount  objective values – health – what should you do for the patient/what does the patient want • patient might be confused, but they should want those things • physicians – do their best to promote those values and do what’s best for them even if they don’t want to accept it o C. what does the patient want? what SHOULD the patient want? o D. - what would it recommend in terms of the Starson’s case? o he is confused – failing to see what’s good for him – override his own judgement  justified in overriding his decisions because it’s good for him – do what it takes to promote that - conflict of values – health is valuable but there are other values in play – wants to have a sharp mind, his creative capacity o how can we say health wins out the conflict? – we’re not entitled to assume that we know what the patient values the most – he may not value health over other things – give a reason to reject the paternalistic model o physicians and patients don’t have the same values and don’t weigh them in the same way - not much role for the rights of patients in this model – main focus on benefit and health o expertise is valued in this model 2. Informative Model - doctor’s role: give the patient all of the information - patient’s role: use that information to decide what treatment is best for them - doctor must then provide the intervention that the patient selects - don’t assume they know about the patient’s values – only gives the patient facts o consumer model – patient as the consumer o A. provide information, provide intervention that patient selects o B. to provide the correct information o C. patient ranks his/her values and decides the outcome o D. patient control over medical decision making - is this the ideal model? 3. Interpretive Model - physician is in some sense a counsellor or advisor that helps the patient understand her values - difference between informative – assumes you know your values and they are fixed o interpretive – don’t always have a clear idea about your values – might not know w
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