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What is consent part 1
- 1. What is Consent? How do we Respect Autonomy? Week 3: The Evolution of Bioethics: Autonomy and Informed Consent
- 2. Getting Consent Usually Involves 3 Components: 1. Determining capacity to consent 2. Informing of diagnosis, prognosis and risks 3. Receiving explicit consent (such as a signed form)
- 3. Determining Capacity for Consent Formal Interviews generally involve evaluating 4 abilities: 1. The ability to understand information about treatment 2. The ability to appreciate how that information applies to their situation 3. The ability to reason with that information 4. The ability to make a choice and express it
- 4. Determining Capacity for Consent Formal Interviews generally involve evaluating 4 abilities: 1. The ability to understand information about treatment 2. The ability to appreciate how that information applies to their situation 3. The ability to reason with that information 4. The ability to make a choice and express it But such capacity is sometimes hard to determine and may change throughout treatment…
- 5. The Case of Linda 1. “Insight”: Patients should be aware of the nature and course of their own illnesses 1. Lack of medical knowledge 2. Inability or unwillingness to internalize the information 3. Distress, fear and other clouding factors 2. Refusal due to stigma or other social influences 3. Varying Lucidity
- 6. Official Code of Ethics for Nurses 1. The patient’s interests are primary a) But how do we determine those interests? 2. Patients have a right to self-determination a) Need to be provided with accurate, complete and understandable information b) Assisted with the weighing of benefits and risks c) Right to accept or refuse treatment without undue influence or duress d) Includes taking into account their religious views and value system 3. Hierarchy of Decision-making a) The Patient b) Designated Surrogate deciding as patient would based on patient’s own values c) Best interest of the patient, including her values a) “Thank You Theory” of compulsory treatment
Notas del editor
- Getting Informed Consent requires more than just getting a signature on a form…[Read text]We will, for the most part, ignore the third component, except to discuss its insufficiency. Instead, we want to focus in on the first two components to understand what justifies them as part of the Doctrine of Informed Consent and what, more specifically, they require…
- The job of determining someone’s capacity for decision-making is everyone’s job. General practitioners do it, usually informally, every time they see a patient. Moreover, anyone involved with a patient in a professional capacity can raise red flags regarding capacity. It is usually only when red flags have been raised that a mental health or ethics professional will be called in to evaluate the patient.So while many times capacity is determined informally… [read]
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- Linda’s situation, as described in “God Knows Where I Am” is a useful study in the difficulties associated with determining capacity for decision making in a medical setting.Although some may want to just write her off as “crazy” and therefore clearly incompetent, the case is not so simple. Moreover, although she was arguably mentally unstable, many of the sorts of behaviors she exhibited may be exhibited by many patients in a medical setting…I think there are three major features of Linda’s case that we can generalize to many patients…[read 1]: While Insight is a psychiatric term, Aviv points out that the idea of being aware of the nature one’s illness is implicit in the Doctrine of Informed Consent. Yet it is not an easy thing to truly understand one’s diagnosis and prognosis, especially if it is out of the blue, as when a routine check-up turns into a cancer diagnosis.Such understanding is complicated in at least three ways: patients may have a lack of medical knowledge that makes the information hard to understand; they may understand it generally but be unable or unwilling to internalize it; they may be unwilling to recognize that what they were just told is happening to THEM. This is often a problem when it comes to internalizing the risks of various procedures. Patients can repeat the risk information, so they heard it and understood it, but they don’t see the risks as applying to them.Finally, both of these issues can be complicated by distress, fear and other clouding factors that come along with being given bad news, being in a hospital setting, or simply being ill or injured.[read 2]: Certainly in the case of mental illness, it is not hard to understand someone fearing being stigmatized. But stigmatization and other social influences can alter a patient’s thought processes or influence her decision making in various ways. Some illnesses have various stereotypes attached to them: HIV, some forms of Hepatitis; but even just being sick at all can be stigmatizing. Moreover, social influences, such as feeling like a burden on one’s friends and family can cause one to reason differently than they otherwise would. Complicating this further, some of these concerns – such as financial burdens – are not clearly unreasonable concerns for someone to have. So there are two problems: determining if they are influencing the patient, and determining whether such influence is problematic.[read 3]: In defense of the hospital and doctors that released Linda, the lawyers argued that Linda was in the right state of mind to be released, pointing to the lucid passages in your diary describing her joy at birdwatching and other activities. Moreover, many of the things Linda did seemed quite rational: she attempted to calculate how many apples she needed to survive, and tried to preserve them knowing they would not always be available off the tree. More generally, a problem with determining capacity in patients is that they may appear much more capable with some activities and some decisions than others. Or, a patient may one day be quite lucid and engaged and another day appear much less so. This makes it impossible to simply call someone competent or incompetent and then move on; a person has the capacity for various things at various times or she does not. This has led to a move away from the use of the terms competent and incompetent in the medical setting as a whole.So what is a medical professional to do?...
- The American Nurses Association has a Code of Ethics for Nurses, which gives some insight into how medical professionals have sought to deal with these complications…First, the patient’s interests are primary. But this says nothing of how we determine the patient’s interests.Second, patients have a right to self-determination. This looks familiar from The Belmont Report, but what does it imply?Well, first it requires that patients are provided with accurate, complete and understandable information. Here you can already see it trying to deal with some of the problems associated with patient’s capacity to understand what is presented to them.Moreover, the code says that patients should be assisted with the weighing of benefits and risks. This again speaks to some of the concerns we raised above, as well as some of the concerns raised by Savulescu that we will look at in part 2 of the lecture. Patients should not be left alone to weigh the probability that a procedure will work compared to the probability they will fall prey to a side-effect or risk.Also, it requires that patients be allowed to accept or refuse their treatment without undue influence or duress. The focus here is on undue influence from medical professionals, but we should be concerned about the undue influence and duress that comes along with merely being ill, or being in a hospital, or receiving complete information about a procedure, including highly unlikely but devastating risks.Finally, it includes taking into account their specific religious views and value system and allowing them to make determinations based on it, regardless of whether the medical professional agrees with such beliefs. But here we may be concerned – According to the hospital’s lawyers, Linda had made a conscious decision to pursue an alternative lifestyle. But where exactly is the line between someone who is incapable of making medical decisions for themselves, due to what some may call irrational or absurd beliefs, and someone who is just pursuing an alternative lifestyle?Finally, the code gives us a good guide to the hierarchy of decision-making authority: The patient is primary, if he or she is deemed capable of making decisions.If not, then decision-making is handed over to a designated surrogate decision maker, if one is available. The role of this surrogate is to decide as the patient would him or herself, based on the patient’s own values and prior expressed wishes, to the extent that they are known.Finally, if no surrogate is available then medical professionals are supposed to decide for the patient based on what they believe is in the best interest of the patient, incorporating his or her values to the extent they are known. Along with this final method of decision-making is the “Thank You Theory” of compulsory treatment that Aviv discusses. Sometimes compulsory treatment has been justified by arguing that the patient, once well, will come to recognize that the treatment was in fact in her best interests and thus thank the treatment provider. On this assumption, it is permissible to forcibly treat someone who is deemed incapable of deciding for themselves. But we should worry about the use and abuse of such a justification.The Code of Ethics for Nurses gives us some idea about how professionals have attempted to overcome these complications, but many questions and concerns still remain. The reason for this, as we will see in the second part of the lecture, is that informed consent is grounded, philosophically, in the concept of autonomy. But, unfortunately, the concept of autonomy is perhaps one of the most hotly debated and controversial concepts in all of philosophy, and thus The Doctrine of Informed Consent has inherited many of its complications and controversies.