PHLB09 – Lecture 2
Medical Decision-Making: Patient Self-determination and Deciding for Others:
Standards of Competence
Involving Children in Medical Decision-making
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.
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
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―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‖
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‖:
Voluntary (not coercive – ex. with a gun to your head)
Sufficient information disclosure
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.
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
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
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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
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:
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
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