Who Decides in Health Care?

1
Who Decides in Health Care?

• Ethics Champions
• April 9, 2008
• Carol Bayley, PhD
• CHW VP Ethics and Justice Education

2
Overview

• How self-determination replaced do no harm as
  the first principle in medical ethics
• Elements of informed consent
• Threshold is capacity
• Disclosure, understanding, authorization
• Alternatives
• Substituted judgment
• Best Interest
• When informed consent is necessary the emergency
  exception

3
The Case of Jeanne P.

• 75 Year old white urban widow 3 adult children
• Stage 4 lung cancer (lung removed chemo)
• Stable for five years
• Chemo stopped working tumors grew
• Tumors produce clotting factor.
• Blood thinners produce stroke.

4
Galloping (and incomplete) History of Medical
Ethics

• 2000 years do no harm
• World War II Nazi experiments
• Nuremburg trials, Nuremburg code
• Do No Harm does not work
• Tuskegee, Willowbrook, series of cases in
  development of legal doctrine of informed consent
• The Belmont Report

5
The Belmont Report

• Respect for Persons
• Beneficence (flip side non-maleficence)
• Justice

6
Respect for Persons

• Respect autonomy
• The patient (or research subject) accepts or
  refuses treatment (or participation in research)
• Vulnerable patients (or subjects) are owed
  special protection

7
The (capacitated) patient accepts or refuses
treatment.

• What is capacity?
• What is informed consent?

8
Informed Consent

• Information (clinician-gtpatient)
• Consent (patient-gtclinician)

9
Information

• Disclosure
• Understanding
• Alternatives

10
Consent

• Voluntary
• Uncoerced
• Authorization

11
What is the next best thing?

• Substituted judgment
• Best interest

12
When is informed consent NOT necessary?

• Almost never!
• The emergency exception
• Informed consent is necessary even when
• Patient is unreasonable, angry, tired, scared,
  sick
• Patient seems to be making the wrong choice
• Doctor really knows best
• Its really inconvenient

13
Back to Jeanne P.

• Children know her well, she trusts them.
• Jeanne understands she will die at some point but
  doesnt want to talk about it.
• What is the goal of informed consent?