Unit One: Relationship Between Medical Professionals and Patients
We begin our journey into Bioethics by discussing the relationship between medical professionals and patients. Contrary to popular opinion, this does not simply involve discussing the relationship between doctor and patient though this is an important relationship in the field of medicine. The relationship can be a complex one and there are several ethical issues involved. The source of many of these can be traced to the disparity in knowledge and expertise between the medical professional and patient. Patients seek out medical professionals because they provide a service that the patient cannot easily, or in some cases at all, provide for themselves. The fact that medical professionals possess a specialized knowledge means that they have a certain amount of power in the relationship. This power is contained in some way by the patient's autonomy. This autonomy implies that any treatment that medical professionals suggest should be approved by the patient. The difficulty becomes apparent when we combine the specialized knowledge that medical professionals have and the power this implies with the patient's autonomy and the power that this implies. In order for the relationship to work well each person must contribute to the outcome. Doctors must respect patients' autonomy to make decisions about their health care and treat the patient in a way that conforms to their best interest.
But what happens when these values conflict? One case like this is considered in the Macklin and Sheldon articles in our text and involves treating Jehovah's Witness patients who refuse blood transfusions. This case highlights the conflict between what the doctor considers the best treatment and the patient's autonomy and right to refuse any treatment. But, as with many values in bioethics, autonomy does have its limits. The most important limit is competence. A patient must be competent in order to have the right to consent or to refuse treatment.
There are many standards of competence suggested in the readings. There is the standard of full disclosure where everything is discussed with the patient that is relevant to their condition. However, this is usually seen as too impractical and gives the patient vastly more information than they need or want. The professional standard is one which many doctors prefer because it provides them with an objective standard with which to compare their behavior. In essence, it says to do what other respected professionals in your field do. However, this is regarded as too paternalistic as it seems to deny the patient information they want if it is not commonly given by other medical professionals. The legal standard defended in Canterbury v. Spence is the reasonable person standard. This is usually understood to be simply what a reasonable person would want to know regarding the proposed treatment including the risks and benefits. Of course, this leaves us with the question of what counts as a reasonable person. To help with this other models are considered in the Brody and Buchanan & Brock readings.
In particular, Brody argues that ideally informed consent should be a conversational aspect of the relationship between the patient and the health care professional. However, this lacks the legalistic rigor to insure in an objective fashion that consent has been informed.
Macklin & Sheldon Articles
The case of Jehovah's Witnesses refusing blood transfusions raises some difficult questions in bioethics. There exists a conflict between the patient's right to autonomy and freedom of religious practice and the doctor's duty to give proper medical treatment. Macklin addresses this conflict by focusing on the competence of the patient and making a distinction between three types of patients: the competent adult patient, the minor child patient, and the incompetent adult patient. While the question of competence is one that we will discuss shortly, the main question concerns a patient's ability to make informed decisions.
Another question which can be raised regarding the refusal of medical treatment regards the reasons for this refusal. Macklin points out that regardless of whether the beliefs seem rational, the patient's autonomy allows them to act on these beliefs even if we would do otherwise.
Competent patients: do have the right to refuse life-saving medical treatment on the grounds of the patient's autonomy.
Minor child patients: should be given the treatment even over the religious objections of the parents.
Incompetent patients: can be treated
Sheldon seems to agree in the action that Macklin defends of overriding the parent's decision to treat minor children, but disagrees with the justification involved.
Sheldon criticizes Macklin on several points. First, the use of the terms "harm" and "benefit" seem to be relative to the perspective one takes on the casr of minor children. Given the religious perspective of the parents what counts as harm and benefit will be different than what the physician would consider a harm or benefit. So, to say unequivocally that the child will come to harm as a result of refusing treatment seems unwarranted by Sheldon.
He concludes by saying that since there is no way anyone can truly know what is in the child's best interest we should err on the side of preserving life. Put another way, he says that the state has the responsibility "to make certain that person who make decisions which are irrevocable do so when they are competent." In the case of minor children this is simply not possible since they are by definition incompetent to make medical decisions.
Canterbury v. Spence
Patient's right to consent implies doctor's duty to inform
How much to disclose to insure informed consent?
Full disclosure standard? Too impractical
Professional practice standard? Too paternalistic
Reasonable person standard
two exceptions:
when patient is incompetent
when disclosure would harm the patient's treatment/condition
Brody Article
Legal standard:
Community practice standard: do what other physicians do
Reasonable person standard: what would a reasonable person want to know in these circumstances?
Conversational model: informed consent is a process based on the model of a conversation between patient and health care professional
Transparency standard: "disclosure is adequate when the physician's basic thinking has been rendered transparent to the patient."
Buchanan & Brock Article
Standards of competence:
Minimal standard: patient is able to express a preference
Outcome standard: is the outcome or decision a reasonable one?
Process standard: focuses not simply on the outcome but the process of arriving at the decision
"Just because a patient is competent to consent to a treatment, it does not follow that a patient is competent to refuse that, and vice versa."
The standard of competence is a sliding scale: the more risk, the higher the standard required for competence.
Tomlinson Article
Criteria of competence:
Understanding
Capacity for communication
Capacity for reason/deliberation
Set of consistent stable values
"competence is not a matter of degree but of threshold"
"refusal [of treatment] is never in itself sufficient evidence of incompetence"
But what happens when these values conflict? One case like this is considered in the Macklin and Sheldon articles in our text and involves treating Jehovah's Witness patients who refuse blood transfusions. This case highlights the conflict between what the doctor considers the best treatment and the patient's autonomy and right to refuse any treatment. But, as with many values in bioethics, autonomy does have its limits. The most important limit is competence. A patient must be competent in order to have the right to consent or to refuse treatment.
There are many standards of competence suggested in the readings. There is the standard of full disclosure where everything is discussed with the patient that is relevant to their condition. However, this is usually seen as too impractical and gives the patient vastly more information than they need or want. The professional standard is one which many doctors prefer because it provides them with an objective standard with which to compare their behavior. In essence, it says to do what other respected professionals in your field do. However, this is regarded as too paternalistic as it seems to deny the patient information they want if it is not commonly given by other medical professionals. The legal standard defended in Canterbury v. Spence is the reasonable person standard. This is usually understood to be simply what a reasonable person would want to know regarding the proposed treatment including the risks and benefits. Of course, this leaves us with the question of what counts as a reasonable person. To help with this other models are considered in the Brody and Buchanan & Brock readings.
In particular, Brody argues that ideally informed consent should be a conversational aspect of the relationship between the patient and the health care professional. However, this lacks the legalistic rigor to insure in an objective fashion that consent has been informed.
Macklin & Sheldon Articles
The case of Jehovah's Witnesses refusing blood transfusions raises some difficult questions in bioethics. There exists a conflict between the patient's right to autonomy and freedom of religious practice and the doctor's duty to give proper medical treatment. Macklin addresses this conflict by focusing on the competence of the patient and making a distinction between three types of patients: the competent adult patient, the minor child patient, and the incompetent adult patient. While the question of competence is one that we will discuss shortly, the main question concerns a patient's ability to make informed decisions.
Another question which can be raised regarding the refusal of medical treatment regards the reasons for this refusal. Macklin points out that regardless of whether the beliefs seem rational, the patient's autonomy allows them to act on these beliefs even if we would do otherwise.
Competent patients: do have the right to refuse life-saving medical treatment on the grounds of the patient's autonomy.
Minor child patients: should be given the treatment even over the religious objections of the parents.
Incompetent patients: can be treated
Sheldon seems to agree in the action that Macklin defends of overriding the parent's decision to treat minor children, but disagrees with the justification involved.
Sheldon criticizes Macklin on several points. First, the use of the terms "harm" and "benefit" seem to be relative to the perspective one takes on the casr of minor children. Given the religious perspective of the parents what counts as harm and benefit will be different than what the physician would consider a harm or benefit. So, to say unequivocally that the child will come to harm as a result of refusing treatment seems unwarranted by Sheldon.
He concludes by saying that since there is no way anyone can truly know what is in the child's best interest we should err on the side of preserving life. Put another way, he says that the state has the responsibility "to make certain that person who make decisions which are irrevocable do so when they are competent." In the case of minor children this is simply not possible since they are by definition incompetent to make medical decisions.
Canterbury v. Spence
Patient's right to consent implies doctor's duty to inform
How much to disclose to insure informed consent?
Full disclosure standard? Too impractical
Professional practice standard? Too paternalistic
Reasonable person standard
two exceptions:
when patient is incompetent
when disclosure would harm the patient's treatment/condition
Brody Article
Legal standard:
Community practice standard: do what other physicians do
Reasonable person standard: what would a reasonable person want to know in these circumstances?
Conversational model: informed consent is a process based on the model of a conversation between patient and health care professional
Transparency standard: "disclosure is adequate when the physician's basic thinking has been rendered transparent to the patient."
Buchanan & Brock Article
Standards of competence:
Minimal standard: patient is able to express a preference
Outcome standard: is the outcome or decision a reasonable one?
Process standard: focuses not simply on the outcome but the process of arriving at the decision
"Just because a patient is competent to consent to a treatment, it does not follow that a patient is competent to refuse that, and vice versa."
The standard of competence is a sliding scale: the more risk, the higher the standard required for competence.
Tomlinson Article
Criteria of competence:
Understanding
Capacity for communication
Capacity for reason/deliberation
Set of consistent stable values
"competence is not a matter of degree but of threshold"
"refusal [of treatment] is never in itself sufficient evidence of incompetence"