Lecture 8: Principles of Autonomy and Informed Consent

refuse treatment

A competent and informed person has there right to ------ ------

patient self-determination act

A federal law that mandates that patients are informed of their ability to accept and refuse medical care and make advanced directives. This act is intended to protect the views of the patient if they become incompetent. (includes the two types of directives)

She was a woman in her early 20's who experienced anoxic brain damage, which left her unconscious (known as persistent vegetative state). She was maintained under life support for a year. Her family decided that she would have preferred to not be kept artificially alive, but the physicians would not agree to their wishes. When take to the New Jersey Supreme Court, the court decided the Mr. Quinland, father and her guardian, had the ability to have the ventilator withdrawn. Ms. Quiland had her constitutional right to privacy, which was not revoked just because she wasn't conscious and couldn't decide. For the first time, a court supported an individual's rights to refuse medical treatment and supported the ability of a representative to make a decision when a patient is medically incompetent.

Case of Karen Ann Quinlan

Nancy Cruzan experienced PVS due to anoxic brain damage and was given artificial nutrition and hydration. The parents wanted to remove her form life support but physician refused--> took it to the Missouri Supreme Court. The court decided that the Guardians did not have the right to remove her from life-sustaining medical treatment based on an indirect or hypothetical reasoning about her wishes. They needed to provide clear and convincing evidence of what the patient would have wanted (this would allow for a surrogate treatment decision). If there is no clear or conniving evidence, the guardian is obligate to act in the patient's best interest, which the court considered to be keeping her in life support. The family took the case to the supreme court. They decided that the constitution kept the right of liberty interest --> to refuse medical treatment. It also held that the states did not violate the Constitution by asking for clear and convincing evidence. This case established the right to refuse medical treatment.

Case on Nancy Cruzan

Mrs. H is a hispanic 83 year old lady who is in the terminal stages of COPD (chronic obstructive pulmonary disease). Even though she is alert and oriented, her family asks that she is put under hospice care without being informed about her upcoming death and that she is now in a hospice. The hospice staff must move their name tags when they come and cannot tell her why they come see her. During the initial visit of the hospice staff, Mrs. H signs the hospice papers without reading them because her family tells her to do so. Then, a family member signs the papers for her without her knowing.

Describe Mrs. H scenarior (Autonomy)

respect, equally

Some refer to autonomy as the ---- for the individual and include the expectation that everyone is treated -----. Autonomy is linked with Kant's deontological ethics

right to receive adequate information to make an intelligent choice about whether to accept or refuse treatment and the right to refuse treatment for any reason - including quality fo life determined by the individual

State the two rights reserved by the Informed consent doctrine

secular ethics

a branch of moral philosophy in which ethics is based on human faculties such as logic, empathy, reason, or moral intuition

justice: social and distributive justice

a medical ethical value focused on justice. There are two type:

surrogate

a person who can make a decision for another, defined by the law. In medicine, it is someone who has the legal authority to make a decision for an incompetent person

subjective

causation issue: the person claims that if they had known that info they would have not chose the intervention/treatment. It is impossible to prove because anyone can claim that they would have refused if they had known something they claim was not disclosed.

objective

causation issue: the person must prove that a reasonable person would not have chosen the intervention if she had known. Most states have adopted this standard.

a hospice must show respect for an individuals rights by attaining an informed consent form that shows the different types of care and service given by the hospice care that is signed bye very individual, either by the individual themselves or an approved representative.

condition of participation: informed consent (Federal-Hospice)

durable power of attorney for health care (health care proxy)

designates someone to make medical decision for the person if she is in an unconscious or otherwise incompetent state to make her own medical decisions.

Medical ethics

discipline that evaluated the risks, merits, and social concerns of the medical field

advanced directives

documents that tell your physician and medical providers that type of care you desire or do note desire if you are in a situation where you cannot make medical decisions. They delineate what care you do or do not want depending on the severity of the illness and the likelihood of recovery

the person is unconscious or cannot give consent (need emergency treatment) and therapeutic privilege (reveling info will cause a phsychological threat - detriment to patient - and therefore is contraindicated)

exception to the general rule of disclosure

social justice

focuses on determining what is good for the overall society

distributive justice

focuses on the distribution of limited resources

Principle of Individual Freedom

idea that every person should choose for themselves and determine their own life.

living will

instructions set by the patient that state interventions she desires or does not if she is found in a terminal condition or PVS or other irreversible neurological condition (depends on state) and cannot expresses her wishes.

Informed consent doctrine

involves the right to be free from nonconsensual interferences with one's person and makes it morally wrong too force someone to act against their will.

non-maleficence

medical ethical value focused on the avoidance of harm

autonomy, beneficence, non-maleficence, justice (social and distributive)

name the 4 major medical ethical values

paternalism

overriding or ignoring people's preferences in order to benefit them or improve their welfare. This violates their autonomy and is not beneficent, but it is non-maleficent.

understanding

patient has mastered the facts and can see the relations between them at a distance (level of receding info)

representative

someone approve by the state laws to remove medical care or elect or revoke the election of hospice care for an individual with a terminal illness that is mentally and or physically incapacitated.

negligence

term to describe situation: when not releasing all the information to the patient results in them giving consent (would have not if all info was given) and injury or damage results due tot he procedure, it is said to be ----

patient-need standard

the disclosure standard for informed consent that involves releasing information that the reasonable person would want to know, and this info needs to be material to the patient

professional standard

the disclosure standard for informed consent that requires the physician to disclose information that a reasonable and prudent doctor would disclose under a similar situation.

informed consent

the discussion between the provider and the patient about the different options and her condition, not the signing of a consent form

protect people's autonomy, protect the patient's status as a human being, encourage physicians to consider decisions carefully, avoid fraud and duress (threats), foster rational-decision making by patients, increase public involvement in medicine

the informed consent doctrine has 6 functions:

beneficence

the medical ethical value that focuses on the obligation to provide and accept beneficial treatment

autonomy (principe of ---)

the medical ethical value that focuses on the right of the individual to choose between the various alternatives (methods) offered to them and reserves their right to accept or reduce medical treatment. In general, it is the right to self-determination, independence, and freedom.

processing

the patient can integrate the facts into a valuable context

facts

the patients is acquainted with factual knowledge which may be discrete and unrelated (level of receding information)

facts, understanding, processing

the three levels of receiving information

principles

there are numerous methods that suggest how to evaluate the ethics of a situation. Many of them offer ---- that should be though about in the process of making a decision.

the informed decision of the patient after she has received all the information needed to make the decision

to be considered legally valid, a refusal of treatment needs to be base upon .....

understand the treatment, its purpose, and why it's being propose; understand the risks, benefits, and alternatives; understand the consequences of no treatment; have to retain information long enough to use it and weigh out your options

to have the capacity to consent, the patient must be able to:

Living Will and Durable Power of Attorney for Health Care

types of advance directive

Battery theory

unwanted touching is prohibited; not possible in almost all medical jurisdictions. The Informed Consent doctrines was based on this

the condition or diagnosis, the nature and purpose of the treatment, the risks of the treatment, and alternative treatments (things that are known, things that everybody should know, option of no treatment, not all alternatives need to be discussed)

what must be disclosed (4)

the risks and benefits of each alternative treatment and the consequences of no treatment

when revealing the alternative treatments, you have to reveal the (2)

diagnosis, prognosis, available treatments

when revealing the condition, you have to reveal the (3)

nature, purpose, risks, benefits, alternatives, cost

when revealing the proposed treatment, you have to reveal the (6)

above 16, under 16 if you have enough intelligence and understanding to get what is being proposed, parents can give consent for younger than 18 kids if they lack the capacity, if above 18, someone else can't give consent - decision is made by the medical team, but usually consult the family.

who is competent and therefore can give consent: