Medical Decision Making

Nuala Kenny SC, OC, MD, FRCPDepartment of Bioethics (post-rtd)Dalhousie University, Halifax, NS

Ethics & Health Policy AdvisorCatholic Health Association of CanadaOttawa, Ontario

History Respect for autonomy Informed choice

Competence Third-party decisions

Models doctor-patient relationship Shared decision making

History of Medical Decision-making

Hippocratic duty of beneficence Beneficence vs paternalism

Doctor as decision-maker

Modern bioethics

The Traditional Practice

Doctor Decides

Patient Welfare

Peers/Profession

Direct PaymentCare by Families

Modern Bioethics

Inclusion of many voices & perspectives in increasingly complex, value-laden decisions

Principle-based reasoning Respect for autonomy Beneficence Non-maleficence Justice

Elements of Informed Choice:A Tool for Respecting Autonomy

Information Reasonable patient standard Truthfulness vs disclosure

Capacity/competence

Freedom, voluntariness From coercion; from undue fear and

from guilt

Competence

Capacity to indicate a choice

Understanding relevant information

Making a ‘reasonable’ decision

Using rational reasons to reach a decision

Differences re Competence

In Law Here & now decision Presumed Understand the choice & gives reasons

In Medicine Whole person Tested (protected) Understand nature of choice,

consequences and alternatives

Advance Directive:Continuation of Respect for Autonomy

Advance care planning includes a directiveA document made by someone while capable concerning health care decisions to be made in the event that the person becomes incapable to make such decisions in the future Instructional directive (‘living will’)-what or how

health care decisions are to be made Proxy directive -who is to make health care

decisions

3rd Party Decisions

The patient must be incompetent Fluctuating, deteriorating

Information, capacity, freedom A decision must be made The decision must be made as the

patient would want using: Substituted judgment Best interest

Models of the Doctor-Patient Relationship

The paternalistic model

The informative model

The interpretive model

The deliberative model Emanuel & Emanuel

Issues Determining the Doctor-Patient Relationship

The goals of medicine Physician’s obligations Patient values The understanding of patient

autonomy

Emanuel & Emanuel

The End of Medicine

The end of medicine is a right and good healing action

E Pelegrino The Philosophical Basis of Medicine

Some Deeply Problematic Issues

The doctor’s duty to do no more intentional harm than benefit

Confusion regarding “respect for autonomy” of the patient

Confusion re the goals of medicine The problem of futility

Quantitative vs qualitative “Best interest” in a consumer world

Shared Decisions-The Ideal

The doctor’s role is to provide facts about the disease, prognosis & possible treatments (based on evidence of benefit vs risks/harms)

The patient’s role is to provide the values-conception of the good-to evaluate and then select among the options

Difficulties with Division of Roles(Dan Brock)

Doctors’ information as value-neutral

Patients’ values are incorrigible i.e. cannot be mistaken

Assumption that patient values are correct and physician must act on them

When Sharing Breaks Down

Unilateral declarations by the doctor Demands for non-validated and non

recommended treatments by patients; litigation

The crucial need for respectful communication

Inevitable distress and compromise of patient welfare

The End of Medicine

The end of medicine is a right and good healing action

E Pelegrino The Philosophical Basis of Medicine