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PHL283 Feb 3 2011

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Jonathan Peterson

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PHL283 February 3 rd Informed Consent - informed consent o why is it important? What interest does it serve? - Hippocratic oath – doctor knows what to do, the patient is not the expert o patient has a submission to the doctor’s judgements – doctors have an obligation to provide the best treatment that they can - now, informed consent has become a fundamental part of what’s appropriate about medical care - but, physicians have: (against the idea that informed consent is important) – its not necessary because… o 1. doctors have years of expertise o 2. the patients are feeling anxiety, pain o 3. commitment to putting the good of others first – not advance their own interests – adequate safeguard against abuse - so how can we defend informed consent – why is it important? o 1. the right to autonomy – nobody can do something to you unless you consent to you – but why does it support the idea that the consent has to be INFORMED – why is information important, why is a requirement of autonomy? o 2. safeguarding the well-being of the patient – it’s true that we can count on the physicians to be altruistic towards patients, but its not a bad thing to have another layer of protection – and the physician doesn’t always know what your values are 1. develop a concept of informed consent 2. is it an ideal that we can achieve? 3. models of informed consent – different ways of understanding what this ideal requires – what counts as an adequate disclosure? 4. J.W and informed consent 1. - what does the model of informed consent look like? - people have to be able to consent to things going on that involve them - what exactly do we mean when we say “informed consent” - in informed consent, what should the patient know? o the risks of the procedures, probability of risks o other alternatives o benefits o do they want that procedure in the first place o walk them through the procedure – what are they consenting to? - certain types of information that the physician must disclose to the patient - what would it take for a person to refuse treatment under informed consent Faden and Beauchamp - autonomous authorization o a particular action that a patient does to authorize a medical personnel o or when a research patient authorizes the “scientists” - what it cant be – o agreeing to go along with something o ex. Dax’s mother – had to sign the forms – had to go along with what the doctors say o can’t be submitting to someone’s will – can’t go along with someone else o not a submission to the will of the doctor - authorization: o involves a transfer of authority  have to understand what you’re doing – have to be intending to do that  otherwise, true consent is not there - also intend to assume responsibility to what the doctor does - what kinds of things have to be in place – what are the conditions? What is required if you’re going to autonomously authorize someone? o 1. standard of competence – able to understand the risks/benefits – how things connect to your values – relate what’s going on to your goals – has the capacity to understand o 2. adequate disclosure of information – tell them the risks/alternatives/benefits/results of refusal o 3. patient has to understand the information – otherwise the consent is not informed – has to actually understand o 4. decision made by the patient has to be voluntary – patient should not be subject to coercion or undue manipulation o 5. the act of consent or refusal 2. - is informed consent an achievable ideal? - 2 notions of informed consent out there – 1. autonomous authorization – you are thinking about the patient and their condition 2. effective consent o legally effective authorization – the institutional/legal requirements that are in place that tell you what counts as consent to a procedure o the paperwork that is needed to do o not thinking about the autonomy of the patient, rather regulating their behaviour – complies with the rules of obtaining consent o rules requiring signatures, witnesses, how much information should be disclosed, the capacity of the patient’s autonomy to give consent - you can have autonomous authorization without effective consent and can have effective consent without autonomous authorization - problem that arises when the two come apart (ex. twin kidney dilemma) o tension between bureaucratic and institutional needs o legal requirements take us farther away from autonomous consent 3. - the models of informed consent - what is the standard to determine whether or not the doctor has told the patient everything they need to know o old: community practise standard – physician based – what doctors normally do in situations o more recently: patient based standard  how do we know what’s adequate? – what do the patients need to know?  objective standard – ideal of a reasonable patient – what would this person need to know in order to make a decision about this particular kind of case?  subjective standard – what do YOU need to know – not the “reasonable patient” but YOU • the time it takes to disclose all the information is too much – gives the comparison of seeing 1 patient a day vs. 5 – but it depends on how high the stakes are • how are doctors going to react in terms of how they approach the issue of informed consent if they have to disclose all the risks? – what’s going to happen is that they are going to focus on risks rather than benefits – informed consent will become a procedure of going through every possible risk Reibl vs Spence - underwent surgery – everything in the surgery was done properly - during or sometime after, Reibl suffered a stroke that left him paralysed in the right side of his body - he claimed that the physician did not inform him of the risks of the stroke - the likelihood of the risk of stroke was very small so he was not told about it - Reibl case introduced the patient based standard into Canadian law - in the community based standard, the physician did nothing wrong, the risks were very small - objective standard – normally, patients don’t need to know all the risks - the subjective standard – what did Reibl need to know? - because Reibl couldn’t keep working after the surgery and stoke, he lost his pension – he said if he was known there was this risk, he would’ve chosen to wait until he got his pension – the risk of a shorter life would have been worth it Brody/Katz - worries about he reasonable p
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