VLE & SocPop Flashcards
What are the 4 forms of autonomy?
Principled autonomy: Implies obligations as well as rights
Relational autonomy: Importance of family in decision making
Autonomy as identity: Important in situations where capacity is lacking e.g. dementia
Procedural autonomy: Criteria for legal capacity
What are the 3 conceptions underlying autonomy?
Bodily inviolability: Links to legal concept of battery
Freedom from interference: Free choice, implications for restraint
Self determination: Implies life goals, higher and lower order desires
What is principled autonomy?
Responsibility on the decision-maker to make choices within the specified moral framework in order to be truly autonomous
Requirement that the patient makes a settled choice in relation to medical treatment responsibly and in consideration of others
What is relational autonomy?
Autonomy is embedded in social relationships
Autonomy is expressed in terms of social relationships
Implications for health care: Role of family in medical decision making
What is procedural autonomy?
Capacity and consent criteria
Person required to demonstrate certain criteria before judged to have autonomy, usually cognitive criteria
– Capacity test (MCA 2005)
– Requirement for ‘substantial degree of understanding’
– Requirement for critical reflection
What is the Legal requirement to respect autonomy?
Treatment without consent is battery (common law)
A person is not to be treated as unable to make a decision unless all practicable steps to help him to doso have been taken without success Standard of care for provision of information -what that person would want to know (negligence)
What relates autonomy to capacity?
Capacity is decision specific, Autonomy is a continuum
Person lacks capacity to make one decision, may have capacity to make many others
Even for the specific decision where capacity is lacking, it may still be possible to respect autonomy to some degree
What is a doctors duty of care?
To respect autonomy, act in a patient’s best interests, protect a patient from harm
If an adult has capacity their autonomous decision must be respected even if this results in harm to that person (e.g. refusal of life sustaining treatment) If a person lacks capacity a doctor must treat them according to the principle of best interests and must protect them from harm. Challenges arise for doctors in situations of uncertainty
An adult patient refuses treatment thought by theclinical team to be in their best interests. What do you need to think about?
Do they lack capacity? MCA criteria for capacity
Is their decision properly informed?
Are they being coerced/unduly influenced?
If they lack capacity, how much does their refusal influence your assessment of their best interests?
To what extent can you restrain them to treat in their best interests?
What is abuse?
Misuse of power and control that one person has over another. Where there is dependency, there is a possibility of abuse or neglect unless
adequate safeguards are put in place
Which people are commonly at risk of abuse?
Older person who is particularly frail
Individual with a mental disorder, including dementia or personality disorder
Person with a significant and impairing physical or sensory disability
Someone with a learning disability
Person with a severe physical illness
Unpaid carer who may be overburdened, under severe stress or isolated
Homeless person
Person living with someone who abuses drugs or alcohol
Women who may be particularly vulnerable as a result of isolating cultural factors
What are the principles of safeguarding vulnerable adults?
Empowerment - Presumption of person led decisions and informed consent
Protection - Support and representation for those in greatest need
Prevention - It is better to take action before harm occurs
Proportionality – Proportionate and least intrusive response appropriate to the risk presented
Partnership - Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse
Accountability - Accountability and transparency in delivering safeguarding
What are the 4 concepts of well being and best interests?
Mental state theory: Experiential, what brings about the most happiness for this person
Desire fulfilment theory: Best interests consistent with the person’s autonomous choices
Objective list theory: Set of agreed criteria for achieving well being eg
independence, ability to have meaningful relationships
Composite theories: Combination of different theories
What are best interests?
An adult with capacity is the arbiter of what is in his or her own best interests (respect for autonomy)
Mainly considered by others in relation to those who lack capacity or autonomy
When considered by others there is a requirement to take into account the wishes of the person in so far as is possible (respecting autonomy)
What does the MCA state is in the best interests checklist?
Must consider, so far as is reasonably ascertainable:
Person’s past and present wishes and feelings (and any relevant written statement made by him when he had capacity)
Beliefs and values that would be likely to influence his decision if he had capacity
Other factors that he would be likely to consider if he were able to do so which could include his current level of happiness
How do you decide whether restrain is appropriate?
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
The harm that will occur to the person if you do not restrain and treat them
The harm of restraining them (physical and psychological)
The minimum level of restraint required
The proportionality of the restraint to the benefit of the treatment
What is the legal framework for restraint and deprivation of liberty?
Restraint (short term): Mental Capacity Act
Restraint or detaining a person so that they are not at liberty to leave (longer than necessary for immediate treatment): Deprivation of Liberty Safeguards (DOLS: formal process at an organisational level with
independent oversight)
What are the models of disability?
Medical model
Social model
Interactional or integrated model
What is the medical model of disability?
Disability intrinsic to the individual – individual deficit
Restrictions experienced, attributed to individual characteristics – physical or cognitive impairments
Interventions/services focus on changing or curing the individual with the deficit
Health care professionals role central in treatment
Disabled people are defined and controlled by medicine
What are criticisms of the medical model?
Individualises the issue of disability
Places power in hands of the medical profession
Promotes negative image, disempowered image of disabled people
May be seen as a ‘personal tragedy’
Disabled people’s movement challenged this by raising personal experience of disabled people as primary source of knowledge
Identifying disability as public issue rather than private issue
suggests it needs socio-political responses
What is the social model of disability?
Came about as a result of disabled people’s movements
Shifts focus from individual and intrinsic to the social and extrinsic
Problem faced by individuals not primarily caused by impairments/condition but by the way society is organised
Makes a distinction between impairment and disability
Impairment is bodily, mental or intellectual limitation or condition Disability is loss or limitation of opportunities to take part in society on an equal basis due to social and environmental barriers
Disability not seen as inevitable consequence of living with impairment
Emphasises to adjust environment within which disabled people live: ie remove physical, attitudinal and social barriers to participation
Highly influential model: identifies disability as social oppression that is linked with a strategy for social and political change
Emphasises rights of disabled people to normal life
Give an example of a condition which questions the medical model and supports the social model of disability
Disability is context specific
Example of Achondroplasia: condition resulting in short limbs (is this impairment?)
disability occurs due to lack of adjustments to the environment and due to social and attitudinal barriers
What is the Interactional or integrated model of disability?
Idea that disability results from complex interactions between impairments and the social and cultural contexts
Many experiences previously viewed as inevitable consequences of impairment now regarded as unacceptable and unnecessary
discrimination – violations of human rights
What is the function of the International Classification of Functioning?
Aims to address difficulties with previous classification system: Addresses difference of emphasis implicit in the medical and social models of disability
Establish a common language for describing health to improve communication between different users such as healthcare workers, researchers, policy makers and the public
Provide an international coding system for classifying coding and
functioning
What tools are there for promoting human rights and equality?
International: UN Convention on Rights of Persons with Disabilities (UNCRPD)
National: e.g. UK Equalities Act (2010)
What does the UN Convention on Rights of Persons with Disabilities say about disability?
Establishes that disabled people are not ‘other’, have the same rights and as others
Human rights legislation established a universal standard or benchmark which can be applied
If a disabled person’s experiences fall short of this universal standard, it is understood as a human rights violation
Give some examples of rights covered by the UNCRPD
Equality before the law without discrimination
Right to life, liberty and security of the person
Equal recognition before the law and legal capacity
Freedom from torture
Freedom from exploitation, violence and abuse
Right to respect physical and mental integrity
Freedom of movement and nationality
Right to live in the community
Freedom of expression and opinion
Respect for privacy
Respect for home and the family
Right to education
Right to health
Right to work
Right to adequate standard of living
Right to participate in political and public life
Right to participation in cultural life
What is the UK Equality Act in relation to disability?
Requires equal treatment in access to employment, services, regardless of protected characteristics of age, disability, gender reassignment, marriage, civil partnership, race, religion or belief, sex, and sexual orientation
Definition of disability: A person is disabled if s/he has a physical or mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-day activities
Why is human rights and equality legislation needed in relation to disability?
Disabled people experience social, economic and health inequality: lower levels of participation in all aspects life
Describe the epidemiology of disability and circumstances that disabled people are more likely to encounter
11 million disabled people in UK: 16% working age adults, 45% of people over state pension age, 6% children and young people
More likely to experience poverty than other people
Significantly less likely to be in employment
More likely to experience discrimination at work
3 times as likely to not have any qualification
Over 1/4 say they don’t have choice and control over their daily lives
1/3 report difficulties accessing goods and services
More likely to experience poor health outcomes even unrelated to their impairment eg people with learning disabilities
What types of barriers exist to disabled people?
Environmental
Social
Attitudinal
What is the hierarchy of evidence?
Systematic reviews: meta-analyses, non meta-analytic reviews
Experimental studies: Randomised controlled trials, Controlled trials
Observational studies: Cohort studies, Case-controlled studies
Descriptive Studies: Cross sectional designs
What is a systematic review?
Identify effective, harmful and ineffective health care
Collate empirical evidence that fits pre-specified eligibility criteria to answer a specific research question
Done in as reliable a way as possible – systematically
Explicit methods selected to minimize bias
What are the key characteristics of a systematic review?
Clearly stated objectives with pre-defined eligibility criteria
Explicit, reproducible methodology
Systematic search which identifies all studies meeting eligibility criteria
Assessment of validity of findings of included studies, looking for bias
Systematic presentation and synthesis of findings of included studies
What is a meta-analysis?
Results of individual studies combined to produce overall statistic
More precise estimates of the effects of health care than those derived from individual studies included in a review
Subject to biases that arise from the study selection process, may produce mathematically precise but clinically misleading result
What is a review?
General term for all attempts to synthesize the results and conclusions of two or more publications on a given topic
What is an overview?
When a review strives to comprehensively identify and track down all the literature on a given topic (systematic literature review)
Why use systematic reviews?
Clinicians need to be evidence-based: making judicious use of the evidence, ensuring practice is up-to-date
Busy clinicians need quick and effective ways of identifying what works best for their patient
Refine unmanageable amounts of information
Added power brought by synthesising the results of a number of smaller studies
What types of questions could be answered by a systematic review?
Identify whether what we’re doing makes a difference
Causes of health problems
Know whether we can predict problems and intervene early
Know whether we can prevent problems
Best ways of diagnosing/identifying problems
Extent of a particular problem
How people feel about health interventions or reasons for behaving as they do
How expensive what we are doing is, value for money
What type of evidence is required to analyse how effective interventions are in preventing or reducing the risk of disease?
Review of prevention studies e.g. RCTs
What type of evidence is required to analyse whether a particular public health intervention does more harm than good?
Review of treatment studies e.g. RCTs
What type of evidence is required to analyse whether particular methods of screening enable us to predict particular problems and intervene early?
Diagnostic/screening studies comparing a new diagnostic method with a gold standard
RCTs examining the effectiveness of a screening programme
What type of evidence is required to analyse the risk factors associated with a particular condition?
Review of aetiological studies e.g. cohort or case-controlled studies
What type of evidence is required to analyse anticipating outcomes of particular conditions for groups of individuals?
Review of prognostic studies e.g. cohort or case-controlled studies
What type of evidence is required to analyse the experience or meaning of a particular condition or treatment i.e. what does it feel like or mean?
Review of experiential studies e.g. qualitative
