Changing Relationship

In the past, the physician patient relationship was one of complete trust. Physicians thought they knew everything about medicine, and patients had few other ways of gaining information so they did as they were told.  The relationship was deeply rooted in paternalism.  However, the influx of medical information readily available in our society as well as a new emphasis on personal care is driving patient empowerment.  In addition, the limited time physicians have to spend with their patients have led to less personal relationships and a dramatic decrease in listening to the patient’s concerns and problems.  In our time, physicians have little knowledge of their patient’s desires, mentality, and values, which can affect the way they administer treatment.  One study even showered that resident doctors spend 12% of their time interacting with patients compared to 40% of their time interacting with the computer.  It is difficult to form relationships with patients in this small window of time.

Role of Consent in New Relationship

         Robert Veatch argues that consent it a transition concept, an innovation that is only useful as a transition to a more thoroughly revisionary conceptual framework. Veatch argues that with the little information physicians truly know about their patients, their personalities, and their values, there is no way that they can even guess what is in the overall best interest of the patient.  Veatch believes that in order for a physician to guess what is the best course for the patient, three assumptions must be true regarding a theory of the good.

1. The physician must determine what will best serve the patient’s medical interests.
2. The physician must determine how to trade off health interest with other interests.
3. The physician must determine how the patient should relate the pursuit of his or her best interest to other moral goals and responsibilities that may conflict.

In our day and age, Veatch believes it improbable to expect a typical medical professional to be able to fulfill even one of these, let alone all three.  In addition to arguing that since a physician has little relationship with the patient, they often cannot accurately determine what is in their best interest, Veatch also argues that physicians are only experts in one component of well-being (medical) and therefore are unable to determine what constitutes the good for another being.  

Where Do We Go From Here?

Veatch argues that there are two alternatives to informed consent.  The first option being to emphasize the concept of choice rather than consent.  Since physicians have no way of knowing what is in the patient’s best interest, they should present the patient with a list of plausible treatment options with the potential benefits and risks of each, allowing the patient full autonomy and choice in their course of action.  This seems extremely implausible.  A more realistic, but still a stretch, of an option is pairing physicians and patients based on their “deep interests” including religious and political affiliations, philosophical and social inclinations, and other worldviews.  This would put both provider and patient on the same page of what values are necessary and essential part of health care decision making and allow physicians to provide the course of action that best falls in line with patient’s views and values.

To me, these two alternatives seem a little farfetched.  I think where we need to start is by changing the paternalistic physician-patient relationship to more of a partnership.  Physicians need to embrace listening, and think of themselves as more of a health coach then the end all and be all of medical knowledge.

What is the stance on children’s autonomy? How much involvement should a child have in a personal health-related decision? In “The Place of Autonomy in Bioethics,” Childress writes that “the presence, absence or degree of autonomy is a morally relevant characteristic” (Childress 312). This means that if we are deciding on the level of autonomy for a child, leaving them no opportunity for autonomous decision-making could be a possible violation of respect for autonomy.

Chlidress frames it perfectly: “Complexity of respect for personal autonomy.” In children especially, there is a huge grey area for making autonomous decisions with respect to healthcare. In 1995, the American Academy of Pediatrics released recommendations for pediatric decision-making. The AAP divided children into 3 levels of capacity: lacking, developing, and having capacity to make health-related decisions (Ross). The main guidelines regarding children with less capacity for making decisions include “seeking parental permission,” seeking “third-party mediation for parent-child disagreement,” and overruling the child’s decision if it goes against life-saving treatment. This seems fair, assuming that the child is inexperienced in life, unprepared to make an informed decision, and the parent makes a well-informed decision that is in the best interest of the family. For more mature children, the parent becomes a consultant rather than a consenter (Ross).

The major issue with the AAP recommendations is that no guidelines or tests exist to determine the level of decision-making capacity of a child! This means that the physician or pediatrician is the one who decides whether the parent will be a consultant or a primary decision-maker. Of course, if the parent makes a decision that is “abusive or neglectful,” the pediatrician can overturn that decision (Ross). Also, hospitals normally have an ethics committee that handles these kinds of situations, and issues are dealt with on a case-by-case basis.

Another important point to note is that people exist in and through time and their choices and actions occur over time” (Childress 310). A parent may be the primary decision-maker, but the parent must also think about the child’s future- will this child be happy in the future with the decision the parent made? Could this be a violation of autonomy if the child opposed the parent’s decision? What if the child was at an age that the degree of autonomy was sufficient, but the child’s opinion was still ignored? Childress supports this idea by stating “we also have to put that patient’s present consents and dissents in a broad temporal context encompassing both the past and the future” (Childress 310). Veatch argues against allowing the parents full consent, because they may not actually have the child’s best interests in mind- they think about money, parental obligations and their other children, among other things.

We must not abandon personal respect for autonomy, even in the situation that the patient is a child. A final decision should be balanced and thoroughly discussed and understood by all who are involved. Coercion or force should only be used as a last resort (Ross).  In “Abandoning informed consent,” Veatch says “it would be extremely difficult to determine whether the absolute best choice has been made” by the parent, but after reading these articles I believe their decision should be considered above the child’s or the physician’s opinion.

References:

Childress, James F. “The place of autonomy in Bioethics.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 308-316. Print.

Ross, Lainie Friedman. “Health Care Decisionmaking by Children Is It in Their Best Interest?” The Hastings Center Report. 27.6. (1997): 41-46. Blackwell Publishing Ltd. Web. 23 Feb 2014 http://dx.doi.org/10.2307/3527717.

Veatch, Robert M. “Abandoning informed consent.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 317-328. Print.

http://www.wordle.net/show/wrdl/7588721/Wordle_Children_autonomy created by Jackie Glodener. 24 Feb 2014.

Though the field of medicine during the times of ancient Greeks is very outdated, The Hippocratic Oath is one concept that remains important even to this day. Particularly, there is one line that the general public expects medical professionals to observe: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice” (Tyson). Interestingly, physicians are expected to judge the best interest of the patient in order to do no “harm or injustice,” but how can one person be expected to determine what is best for another person? Of course, any morally sound clinician wants to ensure that the patient receives the best treatment possible, but to accomplish this they must first combine their professional knowledge with the precise knowledge of every patient’s best interests – a feat that is simply impractical.

According to Veatch, in order to implement a treatment while simultaneously respecting the patient’s best interests, a medical professional must adhere to three principles. First, the clinician must ensure that the patient’s medical needs are met; second, the clinician must ensure that the patient’s other non-medical interests are respected; and third, the clinician must be able to uphold various other societal morals and laws even if these may conflict with the patient’s best interests (Holland 320). As Veatch states, all three of these assertions have the possibility of conflicting with each other. For instance, in a case in which a Jehovah’s Witness has a communicable intestinal disease needs to undergo a critical operation, the surgeon explains that the procedure would require an intestinal bacteria transplant (bacteria from the gut of a healthy individual is transplanted in another individual). He offers an alternative treatment regimen that involves cleansing the gut with potent medications, but this has a very high risk of serious irreversible damage. It is in the patient’s best medical interest to undergo the surgery because the risks are lower, yet this would not be in the patient’s best moral interest. The patient may refuse both treatments and may be willing to live with the disease, although she can spread this disease, which is deadly to other individuals. Thus, the clinician is obligated to treat the patient in order to benefit the greater good, yet this violates the patient’s religious interests and/or her medical and autonomic interests. The clinician and the patient could both agree to the alternative treatment, but this encroaches on the patient’s medical interests. The clinician could leave the patient quarantined for the rest of her life, but this would not be in her best medical and autonomic interests. Subsequently, which option is the best for the patient?

In addition to respecting all three of these factors, medical professionals are guessing to determine the patient’s interests. The most efficient way to diminish the amount of guessing which treatment may work best is for the clinician to strengthen their personal relationship with the patient. Unfortunately, even though the doctor can be “generally warm and caring,” patients may still feel as if there is a distance between them and their physician (Chen). Some people have problems that they would not even tell their best friend, let alone a medical professional who might be a stranger to them. To some patients, medical professionals are experts of their body and know what is best for them with regards to treatment. “Some even said they feared retribution by doctors who could ultimately affect their care and how they did” (Chen). An analogous situation is the classroom setting. Some students often feel afraid to question the authority of the teacher, even if it best serves their learning environment, because the teacher has the ultimate say in their grade. In the medical setting, however, the physician has the ultimate say on the patient’s life.

Essentially, it is nearly impossible for a clinician to act fully within the interests of any individual, especially if they do not know the patient on a personal level. In order for the physician to ensure that most of the patient’s needs and desires are met, the doctor-patient relationship must be strengthened. For this to occur, medical professionals should be more personable to patients in order to make them feel comfortable with divulging information. Meanwhile patients should view their physician as just an average human being with whom they can share their opinions and ideas.

Sources:

Chen, PAULINE W., M.D. “Afraid to Speak Up at the Doctor’s Office.” Editorial. Well. The New York Times, 31 May 2012. Web. 23 Feb. 2014. http://well.blogs.nytimes.com/2012/05/31/afraid-to-speak-up-at-the-doctors-office/?_php=true&_type=blogs&_r=0.

Rosenberg, Jennifer. “Typhoid Mary.” About.com. N.p., n.d. Web. 23 Feb. 2014. http://history1900s.about.com/od/1900s/a/typhoidmary.htm.

Tyson, Peter. “The Hippocratic Oath Today.” NOVA. PBS, 27 Mar. 2001. Web. 21 Feb. 2014. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html.

Veatch, Robert M. “Abandoning Informed Consent.” Arguing About Bioethics. Ed. Stephen Holland. New York: Routledge, 2012. 318-28. Print.