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PHLB09 – Lecture 2 Agenda:  Medical Decision-Making: Patient Self-determination and Deciding for Others:  Standards of Competence  Involving Children in Medical Decision-making  Advance Directives  Tutorials start next week! Medical Decision-Making: Patient Self-determination and Deciding for Others How do we determine whether a patient‘s medical choices should be respected? Recall four principles of medical ethics:  Principle of autonomy  Principle of beneficence  Support well-being in most effective way as possible  Principle of nonmaleficence  Don‘t do harm  Considerations of justice  Ex. distribution of social resources, equality of treatments  Problem with appealing to these four principles of medical ethics:  Doesn‘t consider patient‘s family, focuses on patient and physician  Ex. autonomous choice will trump physician‘s knowledge, such as religious choices  Principles are ambiguous – how do we know if we‘re respecting autonomy, what is autonomy, how do we define beneficence, etc.  Ex. death isn‘t always a harm Paternalism: ―the policy or practice on the part of the people in positions of authority of restricting the freedom and responsibilities of those dependent on them in their supposed interest‖ (20).  Ex. believing and trusting without question that the physician had knowledge the patient didn‘t.  It‘s ok to impose a course of action as long as it serves the individual‘s best interest. Paradigm shift:  Respecting patient autonomy involves respecting patient‘s medical choices  If patient is capable of ‗understanding,‘ it is up to the patient to define ‗benefit‘ and ‗harm‘ relative to his/her own conception of his/her own good  For example, two patients may have the same illness and course of treatment, but they could make different decisions.  Patients may have different values (ex. long life vs. quality of life)  Patients have to live with the consequences  Ignoring patient‘s opinion is irresponsible on part of healthcare provider because physician may have a biased view  Patients have freedom of choice, a right, capacity for self-determination, autonomy 1 PHLB09 – Lecture 2 ―Informed Consent‖:  ―Voluntary consent to a treatment made by competent patient or surrogate/representative who is adequately informed of all relevant information pertaining to the treatment and its alternatives‖ (24).  Informed consent necessary to protect individual‘s autonomy, it‘s the patient‘s own choice and understanding, and shows they‘re capable of understanding the information. Components of ―Informed Consent‖:  Consent:  Competence  Voluntary (not coercive – ex. with a gun to your head)  Informed:  Sufficient information disclosure  Comprehension Allan E. Buchanan and Dan W. Brock: “Standards of Competence”  How can we determine a patient‘s level of competence?  Case 1: Scott is schizophrenic and bipolar, he has uttered threats before, courts ordered him to take anti-psychotics. But because he‘s a physicist, he doesn‘t want to dull his intellects.  Courts first agreed that he wasn‘t stable and it was in his best interest.  Issues:  His own autonomy  Issues of social welfare and safety  Standard of competency, he knew the side effects of the medication and knew its effect on his life – able to make an assessment to keep his mental facilities  Has erratic behavior that threatens competence – history of psychosis  Love of science – gives life meaning (expression of underlying goal in life)  However, his actions may not reflect his goals  He‘s rejecting what any other reasonable person would accept, to take the medication – to gain a normal functional life  Quality of life after medication  May actually be contributing to society, his research may be helpful  Family‘s interest?  Important to know if he‘ll follow through with death threats  If doesn‘t take medication – he‘ll be detained, won‘t have access to university equipment to further research  Doesn‘t necessarily show faulty understanding, he knows what he wants, doesn‘t undermine competence, more of character.  Social resources, mental health resources are scarce, if he‘s functional-ish, he shouldn‘t take up space/resources for others. Standards of competence:  Minimal standard of competence  E.g. ability to express a preference  Does this maximally protect choice? – No, too minimal, doesn‘t give enough information about competence (understanding) – to show an opinion that matches with goals and thoughts of well-being. Maximally protects autonomy 2 PHLB09 – Lecture 2  An outcome standard of competence  e.g. the choice represents what other rational people would choose  Does this maximally protect well-being/best interests? – Yes, maximally protects well-being. Because there‘s some objective measure of well-being (ex. it‘s better to be on meds that to be locked in a mental hospital)  Does it protect well-being? Beneficence, how do we define well-being, is it determined by what most people think?  However, it undermines personal values, but the patient may not know about other alternatives.  Every person is unique, there‘s no general consensus that applies to all beliefs, values, etc.  A process standard of competence  e.g. focuses on process of reasoning vs. the content of the choice  Maximally protecting choice is maximally protecting well-being  How does this differ from outcome?  We don‘t care about the final decision, but whether the reasoning was sound. A process standard of competence: Two Questions:  The answer depends on cost-benefit analysis:  1. How well must the patient understand and reason?  Ex. Down Syndrome people  2. How certain must the evaluation be that person has met specified level of reasoning? Relation of the process standard to expected harms/benefits:  Depends on autonomy/gives life meaning  No single standard of competence  We set standards on expected costs and benefits WRT patient‘s underlying goals  If patient isn‘t competent, we‘ll use standard of best interest (ex. amnesia, dementia)  Process standard depends on underlying goals.  Level of reasoning might be ‗competent‘ for some decision and not others  We‘ll adjust bar of competence depending on person  Standard will vary in accordance with expected benefits/harms  E.g. consent/refusal of low-risk lifesaving procedure may require different levels of competence Chart on page 28:  Different levels of competence for different levels of competence  Ex. if deciding on death – high levels of competence, just show higher reasoning  If we don‘t think a person is comp
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