Autonomy and the Right to Refuse Care Flashcards
Define autonomy
The rough idea here is that we ought to respect individuals’ right to choose how to lead their lives.
Autonomy is derived from the Greek autos (“self”) and nomos (“rule,” “governance,” or “law”). It has come to have many meanings, among them the capacity for, or the right to, self- government. We prefer to use autonomy to mean “self-determination.” When the context is clear, though, we will also use autonomy to mean “the right to self- determination.”
1.
The right or condition of self-government.
Freedom from external control or influence; independence.
Similar:
self-government
independence
self-rule
home rule
sovereignty
self-determination
freedom
autarchy
self-sufficiency
individualism
2.
(in Kantian moral philosophy) the capacity of an agent to act in accordance with objective morality rather than under the influence of desires.
Define competence
Competence, also called decision-making capacity, a person’s ability to make and communicate a decision to consent to medical treatment.
Competence is thus central to the determination of consent and reflects the law’s concern with individual autonomy.
A person’s decision regarding medical treatment must be respected when that person is competent to make that decision.
Conversely, if a person is not competent to give informed consent, it is necessary to employ an alternative decision-making process, such as the use of a proxy, to determine whether treatment should be provided.
Define informed consent
permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.
“written informed consent was obtained from each patient”
Explain whether valid consent needs to be informed
Consent must be given voluntarily, the patient must have capacity to consent, and the patient must be informed.
For consent to be considered valid:
- it must be voluntary
- Patients must be free to consent to or refuse treatment.
- Consent should be obtained without duress or coercion.
- the patient must have the mental capacity to consent
- A patient is considered to have the capacity to consent if he or she understands the:
- nature of the proposed investigation or treatment
- anticipated effect of the proposed treatment and alternatives
- consequences of refusing treatment
- A patient is considered to have the capacity to consent if he or she understands the:
- the patient must be properly informed
Understand the relationship between autonomy, competence and valid consent
Autonomy is said to be self-determination. Self-determination requires that one is capable of making the choice in question. If one is not capable of making the choice in question, then obviously one cannot be self-determining with respect to that choice. Also, self-determination requires that one make a free choice. A choice that is made because of coercion is not an autonomous choice. Finally, many (though not all) think that self-determination requires that one’s choice be informed, based on an understanding and appreciation of the situation that one is in, and that one rationally chooses in light of one’s values.
Define paternalism
Paternalism is interference in the liberty of another for that person’s good. There is an ongoing controversy about the extent to which paternalism may be morally justified.
Note: requiring the wearing of masks is justified on grounds of preventing harm to others. It is not paternalistic. A paternalistic measure is one that is justified on grounds of preventing self harm, e.g. a ban on swimming in shark infested waters, or a requirement to wear a helmet while cycling or motorcycling.
Distinguish hard paternalism from soft paternalism; weak paternalism from strong paternalism
Hard paternalism is the interference in a competent person’s liberty for their own good.
Soft paternalism is the interference in an incompetent person’s liberty for their own good.
It is generally recognized that the latter sort of paternalism is much easier to justify than the former. It should also be noted that different philosophers differ slightly on how they define these terms.
Explain whether Mr. Edwards was competent to make his own medical decision to discharge himself from the hospital
The concern about his competence stems from his denial of facts that any reasonable person would see as obvious. (e.g., denial of diagnosis of MS, denial of choking likelihood, denial of medical expertise required during choking events). However, he had a successful life and business because he took great risks, believed in himself, and ignored experts. That success was his evidence. Mr. Edwards built a successful business, in part, by being domineering, independent, eccentric, and skeptical of expert claims. We don’t want to say that he was incompetent just because he has a set of beliefs that others regard as unreasonable. He was capable of understanding his situation. And he was capable of making health care decisions that were reasonable from his point of view. Surely, then, he was competent.
Furthermore, the objective psychiatric evalutation found him to be competent.
And finally, his close friend (also his nurse) also had the opinion that Mr. Edwards was competent.
Warren argues for two points: (1) an additional reason to think Mr. Edwards was competent to make his own health care decisions was that he received a psychiatric evaluation, and was found to be competent; and (2) if one believes in a strong right to autonomy, one is going to want to let people exercise that right if they have been found to be competent by a psychiatrist.
Explain whether Mr. Edwards’ consent to discharge himself was valid
It is generally agreed that a patient’s consent or refusal is valid only if it is informed. However, there is a minority view that valid consent or refusal may be ignorant if the competent individual chooses ignorance. What one needs to give valid consent is the ability to freely decide whether or not one wants to know and understand the relevant information. Mr. Edwards freely decided not to believe the experts’ advice, yet his refusal was valid.
Explain Warren’s reasons for thinking the hospital did not err in releasing Mr. Edwards from the hospital when they did
Warren defends his view that it was not a moral error for the staff to allow Mr. Edwards to discharge himself without further evaluation by appealing to his favoured approach to ethics, social contract theory. He argues that in the original position people would want to protect their interests by insisting on a strong right to autonomy in the real world. This right to autonomy, while not absolute, would prevent others from significant paternalistic interferences in a competent person’s liberty. Warren then argues that Mr. Edwards was a competent person who made a valid refusal of care. To continue to hold him in the hospital against his will would be a significant paternalistic interference, and therefore the hospital staff did not err when they allowed him to discharge himself when they did.
Explain Patrick and Doran’s reasons for thinking the hospital erred in releasing Mr. Edwards from the hospital when they did
Virtue overpowers the right to refuse care (Patrick - “So Mr. Edwards may have had a right to refuse treatment, but respecting this right may not have been the virtuous thing to do, all things considered.”)
- Patrick argues that even if Mr. Edwards had a right to refuse care, it does not follow that the hospital staff should have allowed him to exercise that right, given that it could seriously harm him. The virtuous thing to do may have been to restrict Mr. Edwards’s liberty to prevent him from serious harm or death.
Doubt justifies delay (Doran - “I want to recommend that in potentially serious medical situations, the hospital staff should, among other steps, discuss (as a team) with the patient (and perhaps immediate family and/or caregivers) what the patient’s wishes are, and explain to the patient what their recommendations are, so that an agreement can be struck, or failing that, so that steps can be suggested to patient and family to protect the patient somewhat in case they go AMA. Here I think the insights of care ethics are to the point.”)
- Doran argues that more efforts were required to ensure that Mr. Edwards and his family understood his circumstances and the consequences of him refusing care. Warren thinks that enough efforts were made, and further efforts would have been fruitless.
What is John Rawl’s liberty principle?
John Rawls’s liberty principle states: “Each person is to have an equal right to the most extensive basic liberty com- patible with a similar liberty for others”
Distinguish between weak and strong paternalism.
Recall that paternalism is interference in the liberty of another person for that person’s good.
Weak paternalism is the view that interference with liberty is justified in order to prevent people from behaving in ways that are likely to defeat their goals.
By contrast, strong paternalism is the view that we may legitimately prevent a person from attempting to realize irrational or mistaken goals.
Compare the four models of the physician-patient relationship.
