Chapter2- Patient-Doctor Relationship.docx

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Department
Health Sciences
Course
Health Sciences 2610F/G
Professor
Patrick Clipsham
Semester
Winter

Description
2: Patient-Doctor Relationship February-13-13 1:01 PM THE PATIENT-DOCTOR RELATIONSHIP Informed Consent  Practical application of the principle of respect for patient autonomy  To consent freely patient must be of sound mind and must not be subject to any coercion or undue influence  Consists of two components: o Doctors disclosure of medical information to the patient -diagnosis, prognosis, available and alternative treatments, risks/benefits and consequences of having or refusing treatment o Competent patient decides whether to accept or forego treatment on the basis of this info, one who understands the nature of their condition, consequences of accepting/refusing an intervention for it  Serves as an ethical basis for a patient-doctor relationship characterized by mutual respect and shared decision making  The greater the level of risk in refusing a treatment, the higher the level of competence should be for the patient to make a decision  Less competent a patient and the greater the risk in not intervening, the stronger reasons and justification there are for overriding a patients refusal  Some argue minimal competence is enough for a patient to consent to or refuse a treatment - if patient is competent to accept it they are also competent to refuse it  Competence, risk and invasiveness of procedure  A terminal ill person who is in need of CPR from a stoke, the doctor is not obligated to perform it because it cannot restore her to normal functioning or prolong their life  Patient is not competent to make decisions about treatment, an appropriately designed "surrogate" can decide on the patients behalf, one of 2 ways: o (1) they can make decisions about treatment as the patient would make them if he were competent, exercising substituted judgement o (2) can decide on a course of action that the surrogate believes is in the patients best interests  Patients interests can be expressed in an "Advance directive" such as a living will, autonomous patient can extend autonomy to a time when their no longer competent to make decisions o (1) express what the patient would want doctors to do (or not do) to them o (2) designate an individual to make decisions about treatment "surrogate"  Theme of directive should be regularly updated so that they accord with the patients interests at or near the time when a decision about an intervention must be made  In absence of advanced directive, surrogate can be chosen in the form of a court-ordered guardian  In emergency cases where people are brought into the ER, doctors need not consult with patients or families to make their decisions to intervene, presumption to treat  Parents decisional authority can be overridden in instances of abuse or neglect  Parental refusal of treatment on religious grounds presents unique problem o Doctors have recourse to the legal system to obtain a court order to protect the welfare of those incapable of protecting themselves  Patient who is confused about medical info might ask the physician to make the decision or at least suggest a course of action , patient is transferring autonomy to the doctor BUT voluntary request for help in making a decision could be described as an autonomous act  Some say illness is the main obstacle to autonomy  In times of sickness some patients don’t want ability/opportunity to make decisions about treatment rather a physician who takes control using their professional judgment and still respecting the patients rights and interests  Paternalism: doctor determines what is in the patients best interests  Beneficence: doctor acts to promote the patients best interests as determines by the patient  Idea of patients taking complete control over medical decision- - depicts physician as competent but detached, impersonality in medical profession, misleading distinction b/w value-free info given by physician and value-laden decisions made by patient  Paternalistic, interpretive and deliberative model o Paternalistic - Physician completely determines what is in the patients best interests, with the patient playing a passive role in treatment decisions o Interpretive- physician also provides patient with info about the nature of their condition and the risks/benefits of different interventions  Physician helps the patient to elucidate their values, making them coherent so that the physician can choose a medical intervention that best accommodates these values o Deliberative- physician is engaged in nor only presenting medical info to the patient, also in recommending treatment in line with patients health-related values and preferences  Neither the patient nor physician makes an exclusive decision about treatment, rather decision follows from shared deliberation b/w doctor and patient  Facts and values intertwined in this deliberation  Physician persuades patient but stays clear of undue influence/coercion  Informative model- physician is obligated to provide all the available medical facts, on the basis of personal values patient then determines with treatments to accept or refuse Therapeutic Privilege  Physicians have obligation to disclose relevant medical info to patients so that they can make informed decisions about treatment  Disclosure of info shows respect for patients autonomy and enables patient to make choices that will be beneficial and not harmful o Include info- patients current medical condition, likely progression if not treated, possible interventions, risks/benefits of interventions  Therapeutic Privilege: doctor can withhold medical info when it is potentially harmful to a patient  Most patients rather be told the truth, benefit from a trusting relationship with a physician and honesty in disclosing info more likely then deception to promote trust benefit patient in long-run  Objections to Therapeutic Privilege o Doctors can exaggerate or otherwise make mistakes in assessing benefits/harms of disclosure and nondisclosure o Withholding medical info fails to respect autonomy of patient and fails to fulfill the doctors duties of honesty and fidelity  Patients have right of self-determination and access to all relevant medical info so that they ca
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