Ethical Decision-Making (part 2)
When ethical concerns require careful analysis, the decision-making process and the resulting decision’s soundness should be measured by at least six obligations -- i.e., Does sufficient trust exist among the involved parties for truthful and adequate information to be exchanged? Is the patient’s right to self-determination protected? Is the patient’s consent truly informed? Does the decision promote the wellbeing of the patient? Is the decision just? Is confidentiality ensured?
1. Does sufficient trust exist among the involved parties for truthful and adequate information to be exchanged?
A sound decision requires that truthful and adequate information pass between patients and their physicians. For this communication to occur, the physician must be truly present in mind with his/her patient in order to listen with interest for insight and to avoid steering the patient toward predetermined conclusions. It is the physician’s responsibility to recognize when competing demands for his/her attention so weaken the attempt to listen that important information may be missed.
Both patient and physician should be free to express concern that adequate information has not been shared. A physician should not assume that s/he rather than the patient knows what information needs to be shared. In general, a patient benefits from an understanding of her medical condition, its prognosis, and the treatment/s available. A perception that essential information has been concealed or distorted undermines trust.
A substantial history of continuity of care usually establishes trust between a patient and her physician. Without such experience together, patients and physicians may approach each other more as strangers or even adversaries. This hesitancy is exacerbated when physicians are wary due to the present litigious atmosphere surrounding medicine and when patients are unnerved by the impersonal effect of hospitals. Perhaps the most difficult circumstances in which to establish trust occur when the initial contact between a patient and her physician happens during an emergency.
The ability to establish trust is central to practicing the art of medicine. There will be patients with whom, for a variety of reasons and after considerable effort, trust cannot be established. In such circumstances, the physician should assist the patient in the transfer of her care to another qualified medical professional.
2. Is the patient’s right to self-determination protected?
A sound decision requires respect for a patient’s right to self-determination. This right derives from her broader societal liberty to set personal values of conduct and to choose voluntarily a course of action consistent with those values. Such freedom necessitates that others avoid interfering, except when the individual is not competent to make decisions or when the chosen course of action infringes on the freedom and interests of others. It is a purpose of law to clarify the boundaries within which individuals exercise their autonomy (L., self-law or self-rule).
It is the physician’s responsibility to maximize his/her patient’s liberty to choose the direction, nature, and consequence of her health care. To do so requires restraint. A physician may have to consider an alternate management plan if the patient rejects the course of treatment that the physician judges to be in the best medical interests for the patient. For instance, a physician who advises a woman with a history of life-threatening peripartum cardiomyopathy to avoid future pregnancy is restricted from taking further steps to interfere with her reproductive choices.
3. Is the patient’s consent truly informed?
A sound decision requires that the patient consent to the course of action and that her consent be truly informed. Informed consent is defined as “the willing and uncoerced acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits”. The argument for the informed consent process in medical practice focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).
A patient’s right to make her own decisions about medical interventions extends to her liberty to refuse recommended medical treatment. In 1914 Judge Benjamin Cardozo pointed to the future when he argued that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”. The meaning of consent -- itself still a novelty in 1914 -- expanded by the 1950s to informed consent and by the 1970s to informed choice.
At times, a patient’s capacity to comprehend and process the information presented to her may be in doubt. The physician should, through consultation and further discussion with the patient, attempt to clarify the patient’s capacity to consent. If a patient is unable to consent, a substitute decision-maker should be sought.
1. Does sufficient trust exist among the involved parties for truthful and adequate information to be exchanged?
A sound decision requires that truthful and adequate information pass between patients and their physicians. For this communication to occur, the physician must be truly present in mind with his/her patient in order to listen with interest for insight and to avoid steering the patient toward predetermined conclusions. It is the physician’s responsibility to recognize when competing demands for his/her attention so weaken the attempt to listen that important information may be missed.
Both patient and physician should be free to express concern that adequate information has not been shared. A physician should not assume that s/he rather than the patient knows what information needs to be shared. In general, a patient benefits from an understanding of her medical condition, its prognosis, and the treatment/s available. A perception that essential information has been concealed or distorted undermines trust.
A substantial history of continuity of care usually establishes trust between a patient and her physician. Without such experience together, patients and physicians may approach each other more as strangers or even adversaries. This hesitancy is exacerbated when physicians are wary due to the present litigious atmosphere surrounding medicine and when patients are unnerved by the impersonal effect of hospitals. Perhaps the most difficult circumstances in which to establish trust occur when the initial contact between a patient and her physician happens during an emergency.
The ability to establish trust is central to practicing the art of medicine. There will be patients with whom, for a variety of reasons and after considerable effort, trust cannot be established. In such circumstances, the physician should assist the patient in the transfer of her care to another qualified medical professional.
2. Is the patient’s right to self-determination protected?
A sound decision requires respect for a patient’s right to self-determination. This right derives from her broader societal liberty to set personal values of conduct and to choose voluntarily a course of action consistent with those values. Such freedom necessitates that others avoid interfering, except when the individual is not competent to make decisions or when the chosen course of action infringes on the freedom and interests of others. It is a purpose of law to clarify the boundaries within which individuals exercise their autonomy (L., self-law or self-rule).
It is the physician’s responsibility to maximize his/her patient’s liberty to choose the direction, nature, and consequence of her health care. To do so requires restraint. A physician may have to consider an alternate management plan if the patient rejects the course of treatment that the physician judges to be in the best medical interests for the patient. For instance, a physician who advises a woman with a history of life-threatening peripartum cardiomyopathy to avoid future pregnancy is restricted from taking further steps to interfere with her reproductive choices.
3. Is the patient’s consent truly informed?
A sound decision requires that the patient consent to the course of action and that her consent be truly informed. Informed consent is defined as “the willing and uncoerced acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits”. The argument for the informed consent process in medical practice focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).
A patient’s right to make her own decisions about medical interventions extends to her liberty to refuse recommended medical treatment. In 1914 Judge Benjamin Cardozo pointed to the future when he argued that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”. The meaning of consent -- itself still a novelty in 1914 -- expanded by the 1950s to informed consent and by the 1970s to informed choice.
At times, a patient’s capacity to comprehend and process the information presented to her may be in doubt. The physician should, through consultation and further discussion with the patient, attempt to clarify the patient’s capacity to consent. If a patient is unable to consent, a substitute decision-maker should be sought.
