Balancing Respect For Autonomy & Best Interests Of Adults

Question 1

What is capacity?

Answer 1

Legal concept describing something discrete and decision-specific therefore, lacking capacity for 1 thing does not mean a patient lacks global capacity - even if someone lacks capacity to make a specific decision they may not totally lack autonomy so it should still be respected

Question 2

What is autonomy?

Answer 2

Ethical concept describing a continuum - autos (self) nomos (law) meaning:

• Freedom from bodily inviolability, constraint or interference
• Self-determination i.e. freedom to pursue goals according to one’s desires

Question 3

Is autonomy really possible?

Answer 3

1. Biological (genetics), the environment and societal constraints may make it a psychological impossibility
2. In terms of culture, women may not be given the same autonomy level as men

Question 4

Why sometimes may it be beneficial to compromise one’s own autonomy for the better?

Answer 4

Some people will use individualism as a justification for selfish actions but there are just some things that we should not do even if we want too

Question 5

What is Kant’s conception of autonomy?

Answer 5

Principled/moral autonomy: takes autonomy to mean having authority over one’s actions according to one’s will and ability to reason/impose one’s own moral laws - decisions not ruled by emotions (this is why this is not a perfect model as people often make irrational emotionally based decisions)

Question 6

What is Frankfurt’s conception of autonomy?

Answer 6

There are different levels of desire that can be in conflict with one another:
1. 1st order desire: to want something
2. 2nd order desire: to want to want something
… The further down you go, the closer you are to your actual will

E.G. a person who wants to quit smoking:
1st order desire = to have a cigarette
2nd order desire = to want to not want a cigarette

Question 7

What is relational autonomy?

Answer 7

Embeds agency and autonomy within social context rejecting over-idealised aspects of autonomy

Question 8

How should we value autonomy?

Answer 8

1. Instrumental or final/intrinsic? (Mill Vs Kant) i.e. sometimes people may want something may makes them miserable but should we just accept their decision as final no matter what the outcome?
2. Autonomy as generating prima facie (accepted as correct or proven otherwise) or absolute duties?
3. Primacy/priority of autonomy (libertarianism)
4. Respect autonomy or actively promote it (-ve versus +ve duty)?

Question 9

What is the Beauchamp and Childress perspective of autonomy?

Answer 9

An autonomous choice is a decision made by a person that is deemed competent with no external coercion i.e. not concerned with internal coercion and conflict of desire - most common meaning of autonomy underpinning most consent practices

Question 10

What must be considered if abiding by Beauchamp and Childress’ perspective of autonomy?

Answer 10

Information that is given to the person allowing them to make an autonomous choice and how much information is needed for that to be possible

Question 11

What is Ulysses contract?

Answer 11

Short-term restrictions on autonomy that may enhance autonomy in the longer term (consequentialism vs deontology) e.g. a patient may agree to this if they have an episodic mental health condition where their mental health may lead to refuse treatment that will be beneficial to them

Question 12

What are the legal requirements of respecting autonomy?

Answer 12

1. Common law: treatment w/o consent = battery
2. MCA: a person is not to be treated unable to make a decision unless all practicable steps to help him/her to do so have been taken w/o success
3. Negligence: standard of care for provision of info (what that person would want to know)

Question 13

What is doctors duty of care?

Answer 13

1. To respect autonomy
2. To act in patient’s best interests
3. To protect patient from harm

I.E. MAKE CARE OF PATIENT 1ST CONCERN

Question 14

How can you respect a patient’s autonomy?

Answer 14

• Treat as individuals + respect dignity
• Listen + respond to concerns/preferences
• Give info they want/need in a understandable way
• Respect right to reach decision with you about treatment/care
• Support them in caring for themselves to improve/maintain health

Question 15

What is the difference in your approach as a doctor regarding decision making if a person has capacity, in contrast with if they do not?

Answer 15

Capacity: decision must be respected even if this results in harm to that person e.g. refusal of life sustaining treatment

Lacks capacity: treat according to principle of best interest and protection from harm

Question 16

How would you investigate a patient’s capacity?

Answer 16

1. MCA capacity criteria
2. Capacity assessment (4 aspects)
3. If any are missing, undertake full capacity assessment

Question 17

What questions must you ask yourself if an adult patient refuses treatment thought to be in their best interest?

Answer 17

1. Do you have reason to think they lack capacity?
2. Is their decision properly informed?
3. Are they being coerced/unduly influenced?
4. To what extent can you detain or restrain them to treat in their best interest?

Question 18

What are the different conceptions of best interest?

Answer 18

1. Most +ve mental state (happiness): experiential observation determining what brings about the most happiness for this person
2. Desire fulfilment: best interests tied to person’s autonomous choices (even if it might not make them happy)
3. Objective list: set of agreed criteria for achieving wellbeing e.g. independence, ability to have meaningful relationships, knowledge

Question 19

According to the Mental Capacity Act (MCA), the person making the determination of best interests must consider so far as is reasonably ascertainable:

Answer 19

1. The person’s past and present wishes and feelings (in particular any relevant written statement made when he/she had capacity)
2. The beliefs and values that would be likely to influence decision if he/she had capacity
3. The other factors that he/she would likely consider if able to do so

= autonomy + best interests

Question 20

What best interest concept does the Mental Capacity Act (MCA) line up most with?

Answer 20

Desire fulfilment

Question 21

In considering whether to restrain a person or to deprive them of their liberty in order to treat them in their best interests, you need to consider:

Answer 21

1. The harm that will occur to the person if you do not restrain and treat them
2. The harm of restraining them physically and psychologically
3. The minimum level of restraint required
4. The proportionality of the restraint to benefit of the treatment i.e. the severity of each should match each other

Question 22

What 2 duty’s does restraining a person bring into conflict?

Answer 22

Duty to respect a person’s autonomy VS duty to protect them from harm

Question 23

What legal framework covers short-term restraint?

Answer 23

MCA

Question 24

What legal framework covers longer term restraint/detainment?

Answer 24

Deprivation of Liberty Safeguards (DOLS): formal process at an organisational level with independent oversight

Question 25

What adults should safeguarding duties be applied to?

Answer 25

Any adults who meet the following criteria:

1. Has care and support needs
2. Is experiencing or is at risk of abuse or neglect
3. Is unable to protect themselves because of their care and support needs

Question 26

Who might be at risk of abuse or neglect and therefore, may need to be safeguarded?

Answer 26

• A particularly frail older person
• An individual with a mental disorder inc. dementia or personality disorder
• A person with significant and impairing physical or sensory disability
• Someone with a learning disability
• A person with a severe physical illness
• An unpaid carer who may be overburdened, under severe stress or isolated
• A homeless person
• Any person living with someone who abuses drugs or alcohol
• Women who may be particularly at risk as a result of isolating cultural factors

Question 27

What must be done if an adult is identified with safeguarding needs?

Answer 27

1. Identify adult with safeguarding needs
2. Respond to immediate risks
3. Assess individuals ongoing needs
4. Assess capacity
5. Identify relevant services
6. Seek consent
7. Review