The Patient-Doctor Relationship (Biomedical Ethics)

Charles Lohman

Informed ConsentThe 2 Components

• INFORMED CONSENT – a practical application of the principle of respect for patient AUTONOMY– The 2 components:

• 1.) DOCTOR’S DISCLOSURE – DOCTOR’S DISCLOSURE of medical information to the patient

includes diagnosis, prognosis, available, and alternative treatments, and the risks, benefits, and consequences of having or refusing treatment.

• 2.) COMPETENT PATIENT– The COMPETENT PATIENT can decide whether to accept or refuse

treatment on the basis of the DOCTOR’S DISCLOSURE.» The COMPETENT PATIENT is one who understands the

nature of their condition and the consequences of accepting or refusing an intervention for their condition.

Informed ConsentBeneficence -v- Autonomy

• If the patient is a COMPETENT PATIENT– A patient’s AUTONOMY outweighs a doctor’s duty of

BENEFICENCE.– A patient’s AUTONOMY is consistent with the doctor’s

duty of NON-MALEFICENCE.• If the patient is NOT a COMPETENT PATIENT– Some say use a SLIDING SCALE

• They say the required level of COMPETENCE should be on a SLIDING SCALE from low to high risk.– A physician’s PATERNALISM can outweigh a patient’s AUTONOMY and an

intervention can be JUSTIFIED.

– Some say MINIMAL COMPETENCE • They say a patient with MINIMAL COMPETENCE is enough for a

patient to accept or refuse treatment.

Informed ConsentDesignated Surrogate

• For a patient that is NOT COMPETENT, a designated SURROGATE can decide on the patient’s behalf.– A SURROGATE can act in 2 ways.• 1.) The SURROGATE can make decisions about

treatment as the patient would make if he/she were COMPETENT, thus exercising substituted judgment.• 2.) The SURROGATE can decide on a course of action

that he/she believes is in the PATIENT’S best INTEREST.

Informed ConsentAdvance Directive

• A patient’s INTERESTS can be expressed in an ADVANCE DIRECTIVE– For example, a living will allows an AUTONOMOUS

patient to extend AUTONOMY to a time when he/she is no longer COMPETENT to make decisions.

• ADVANCE DIRECTIVE can serve 2 goals.– 1.) It can express what the PATIENT would want

doctors to do or not do.– 2.) It can designate an individual to makes decisions

for the PATIENT.

Informed ConsentParents -v- Child

• IN GENERAL, parents can make decisions about their children’s TREATMENT because they are the best JUDGES of their children’s best INTERESTS.– A parental refusal of an intervention should be

respected.• BUT the parents DECISIONAL AUTHORITY can be overridden

if it causes direct and serious harm to the child.

– MATURE MINOR can exercise personal AUTONOMY as long as they are not overly influenced or coerced by his/her parents.

Informed ConsentPatient-Physician Relationship Models• INFORMATIVE model - The patient applies personal

VALUES to determine which TREATMENTS to ACCEPT or REFUSE.

• PATERNALISTIC model - The physician completely determines what is in the patient’s best INTEREST independent of the patient’s VALUES.

• INTERPRETIVE model - The physician chooses a medical intervention that best fits the patient’s VALUES.

• DELIBERATIVE model - The decision about treatment follows from SHARED deliberation between physician and patient.

Therapeutic Privilege

• THERAPEUTIC PRIVILEGE - a doctor can WITHHOLD medical information when it is potentially HARMFUL to a patient.

• Two main objections– 1.) Doctors can exaggerate or otherwise make

mistakes in assessing the BENEFITS and HARMS of disclosure and nondisclosure.

– 2.) WITHHOLDING medical information fails to respect the patient’s AUTONOMY and fails to fulfill the doctor’s DUTIES of HONESTY and FIDELITY.

Confidentiality

• CONFIDENTIALITY - a doctor discloses medical information about a patient to the patient alone.– The duty to inform can override the duty to uphold

CONFIDENTIALITY in specific instances.

• Two arguments supporting physician’s obligation to uphold CONFIDENTIALITY with their patients.– 1.) Respect for the patient’s AUTONOMY and PRIVACY– 2.) Keeping TRUST between doctor and patient

Cross-Cultural Relations• The meanings Western doctors and non-Western

patients attach to terms may be reflections of DIFFERENT belief systems.– This can be accommodated within a broad Western model

of INFORMED CONSENT.• Example, NONMALEFICENCE and BENEFICENCE

– Explaining the reasons for treatment(s) in culturally different terms is an alternative way to adhere to the duties of NONMALEFICENCE and BENEFICENCE.

• Example, Autonomy– In some cultures, it may be common for a competent adult to freely

delegate DECISIONAL AUTHORITY to another adult. Although this differs from the Western liberal understanding of INDIVIDUAL AUTONOMY and INFORMED CONSENT, it can be interpreted as a different expression of AUTONOMY and CONSENT.