O’Neill (2004) provides a strong argument that the ethics of informed consent cannot be extended to public health provisions.  The rationale for this argument is that informed consent is a right that can inherently only benefits individual agents, not the health of an agent overall.  Cases like the spread of infectious diseases factor importantly in this discussion, because an individual’s decision to forgo certain public health provisions (i.e. vaccination, treatment of the disease) affect the population overall.  On O’Neill’s view, informed consent is a moral principle that should guide individual interactions between a doctor and their patients.  In this post, I will entertain an alternative hypothesis—that informed consent cannot be abandoned in public health policy.  From this, it can be decided if a tenable approach to public health can surface.  Ultimately, I conclude that it cannot.

Under a model of public health that does not abandon informed consent, no public health policy would result in a compulsory action.  Informed consent, in itself, would be considered a public good, on the same level as the prevention of disease transmission.  Public health policies would not be laws in the true sense, but guidelines.   A salient example is vaccination.  Suppose the legislature of country X passed a vaccination law with the goal of stopping the spread of some disease.  For the goal of preserving individual autonomy, the law has a clause which permits individuals to forego vaccination.

We must examine several possible consequences of individuals foregoing vaccination in country X.  It is possible that nobody would be vaccinated.  In this case, the spread of disease would be a necessary victim to preserve autonomy.  A second possibility is that everybody is vaccinated.  In this case, both the goal of preserving autonomy and of preventing the spread of disease are met.  A third possibility is that some people are vaccinated and some are not.  In this case, informed consent is preserved, but the spread of the disease is only partially curtailed.

Among these possibilities, the second and third seem to be desirable public health goals. (Note that, for the sake of this argument, I am not considering compromised herd immunity to be a variable.)  But only the second possibility effectively deals with the spread of the disease, and thus the only one that maximizes the public good.   If we examine the first and third cases, where some or all of the population chose not to obey the public health provision, we can clearly see that informed consent should not be afforded a privileged position in public health policy.

In the cases of informed consent that we have examined so far, the results of foregoing treatment were at worst detrimental to the individual’s health.  But public health is qualitatively different from individual health choices.  The goal is not treatment, but prevention.  Autonomy in treatment means that the person being treated can, ultimately, make his own decisions.  Does it even make sense to speak of autonomy in prevention on a group-level?  I doubt that it does.  After all, decisions (like foregoing vaccination) do not just have individual consequences, but group-level ones.  If we are to posit that public health policies should maintain individual autonomy, we are, in effect, not even making public health decisions.

Works Cited

O’Neill, Onora. 2004. “Informed Consent and Public Health”, Philosophical Transactions:           Biological Sciences 359 (1447): 1133-1136.

Julian Savulescu and Richard W. Momeyer’s article “Should Informed Consent Be Based on Rational Beliefs?” gives its readers a fresh perspective on consent not yet addressed by other authors in Arguing about Bioethics, by Stephen Holland, and it is one that happens to be very critical of the different thought processes that arise in choice making and their logical soundness.

This entails dissection of various situations of a theoretical person but they are always somehow placed in an inferior position- the relating of example stories to theory heavily place the decision-making critiques on the patient, in the case of a patient-doctor relationship. The authors do little to provide ways of evaluating the differences between each of the unsuccessful outcomes, and solutions that are reached in this article speak to things that doctors can do better, not patients, lawyers, and others who could benefit from being more self-aware. It is this self-awareness that would in fact solve their three cases of holding false beliefs.

First of all, there is the heavy reliance on Jehovah’s Witnesses as their go-to example (it is not as easily relatable for non-religious people and definitely not a reliable example across universal belief systems) and this shows a weakness in their article on the most general level. This is so as such reliability on only one specific case is in a way “taking the easy way out” and not showing how their perspective is crucial to the success in every case.

The authors provide smaller example situations with characters such as “Author 1” which are better in generalizability but contain gaps still. As these authors proceed to be so critical of the thought-processes described, I too will show that with the same criticism their overall argument lacks a final impression that motivates change.

A first gap occurs on page 329, when they claim more information to patients must be given, and that is must be relevant. A lack of discussion on what is “relevant” is a gap because it is later crucial in their 3 “Author” examples; they demand that the unknowing person somehow should make themselves informed of things they would not even consider possible in their situation in order to make a their beliefs true. Thus it is crucial to understand what relevant information is so that decisions can be both rational and based on true beliefs, and the person can as a result truly be autonomous. It is now clear that a gap would remain without a discussion on relevancy.

As the authors attempt to apply a case of Jehovah’s Witnesses to patient-doctor relationships, they do use useful sub-examples of a character intending to put out a fire. Something interesting they claim in the process, however, is that sometimes people are unsuccessful in their decisions because the do not care to inform themselves. They then say this results in both practical and theoretical failures. I believe this is inconsistent, as this leads to a result of failed thinking, which has practical implications. The authors may want to revisit such examples with a more philosophical eye- by this I mean checking the validity of their statements to ensure their effectiveness. In the world of Logic, a perspective within the broader study of philosophy, it is possible their article has several fallacies. This word at its root “fallare” means “mistake” in latin. In this case, we see fallacies of “begging the question”. In addition, although  contradictions are still valid by definition, any that come up in the article take away from consistency in argument. It is clear how this takes away from its degree of conviction.

The final takeaway of this article is indeed more along the lines of having the patient trying to inform themselves more, as hinted at on the conclusion of page 337.  It is slightly concerning, though, that a concrete guide to doing this is not provided.

Savulescu, Julian. and Momeyer, Richard. “Should informed consent be based on rational beliefs?” Arguing About Bioethics. Ed. Stephen Holland. London:   Routledge, 2012. 332. Print.

Within the last generation, the idea of informed consent has swiftly grown in the eyes of the public. While many scenarios focus on the repercussions patients face due to insufficient information, there have also been negative ramifications that have implicated doctors and other health care providers. These professionals face questions like how much information must they provide? How much is too much or too little information? Do information sheets and relevant websites count as the doctor informing the patient, or must certain ideas be specifically vocalized? Within this post, what is not necessary and what is necessary for a doctor to discuss will be analyzed.

The courts of Australia and Great Britain have h eld that when disclosing information, they hold “therapeutic privilege. ” This therapeutic privilege justifies “withholding information that may harm a patient” (Informed Consent: a Lesson from Australia). While at first glance this seems to be protecting a doctor from having to disclose information about heart surgery when the patient is facing a cold, this actually branches out to include a doctor not needing to discuss heart surgery for someone who would be harmed by it, even if they had a debilitating heart condition. In that particular situation, however, a doctor would probably mention the idea of heart surgery, but then clearly explain the risks associated with each particular scenario and offering their own advice as a trained health professional.

On the other hand, when communicating information to the patient about a treatment, doctors should avoid words like “small risk, slight risk, and rare”, as these terms are extremely subjective. Rather, the risks should be discussed in terms of percentages and other numerical ranges that can clearly communicate the actual statistics of the procedure or medication. In addition, a risk does not necessarily have to be life threatening to be disclosed. In “Informed Consent: a Lesson from Australia”, the example of the risk of “faeces leaking into the vagina, which is unpleasant but not life threatening” is one that should be communicated from the healthcare provider, to the patient. The article then goes on to explain that these sorts of potential risks must be clearly communicated by vocalization. It is not enough to simply “providing pamphlets about a proposed procedure”. Holland follows a similar line, explaining that the doctor must “tell” the patient the facts and risks in the form of a clear story (Holland 334).

Overall, there should be a legalized consensus as to what required of a doctor. If there was a chart while demonstrated as to when what information is necessary to be available to the patient, the healthcare provider would simply need to inform the patient based off of the circumstances that have been precedent. Until this clarification has been made, it is vital for the doctor to impart all relevant information, as it is better to over-inform rather than under-inform.

Source:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121943/

The debate over whether an adult patient deserves autonomy, or deserves their autonomy to be respected is a never-ending struggle. Many issues may serve to prevent adults from having their own autonomy, such as the patient’s mental stability, the patient’s ability to verbalize their wishes, and the patient’s age. In order to adhere to the “best interest standard” that Robert M. Veatch discusses, a surrogate must make the decisions regarding the patient’s health plans for the best interest of the patient. As Veatch indicates, this form of deciding what option best suits a patient’s health and life is “complex and subjective” (Veatch 319), especially if the wishes of the patient is not known by the surrogate. There is also a great deal of fog when deciding who can best act as a surrogate and decide the best health option for the patient.

So how does this work for a child? Who serves as their decision-maker; the state, the health-care provider or the parent? And what is the “best interest standard” in their case?

Many obese teens and their parents may be desperately searching for a solution to the problem of obesity and may turn to bariatric surgery. Many families may see this decision as a morally good decision and may support their child in their efforts to live a better life wholeheartedly. As specified by Veatch, well-being will be maximized after bariatric surgery because it would improve psychological, social, aesthetic, and even occupational well-being (Veatch 321).  However, the decision to participate in this life-changing procedure does not reside with the patient or the family, but with the pediatricians, dieticians, social workers, and surgeons that may be involved in the patient’s life. Thus, if these outside individuals did not believe that the patient was “ready” or prepared to partake in this new journey, the patient will be regrettably barred from the procedure. Considering that the patient is able to communicate their desires, shouldn’t their autonomy be respected? Why is the autonomy that stems from a rational decision that is made by true beliefs not respected? And this decision will be made to improve the lives  of the children who want to participate in this surgery, so why won’t doctors allow it?

Circumcision is also another much debated topic that can make one think about where decisions may lie. Circumcision is known to have many benefits such as the prevention of STI’s and the decrease in HIV transmission. Many parents opt to provide their sons with circumcisions at birth and may assume that their sons may not be upset with the decision, however, Frank, an individual from Los Angeles is upset that he had to undergo the painful circumcision and that he did not have an option to say yes or no. While a newborn, the surrogate who can make the decisions tends to be the mother and father and if they choose to perform circumcision, it is because they believe they are practicing good paternal and are hedonistically serving their child’s best interest. However, the child may grow up and not think so. So is it moral that the autonomy of this decision stays with the parent even though the child may not agree with this decision later on? James F. Childress explains that some health care providers may make a decision disregarding patients autonomy believing the patient will “ratify the coercive or deceptive treatment on her behalf, thanking the professional,” (Childress 311).

As infants and children may have the right to autonomy but their autonomy can be overshadowed and disregarded for the decisions of a better informed, more rational surrogate such as a physician and doctor, one can begin to wonder who really deserves to be the voice of the child. In a situation when a child is on life support but has a bleak chance of survival or a good life, does the parent decide to keep their child alive? Should the physician decide to allow the patient to rest at peace? And who is making the “best choice” for the patient?

References:

Childress, James F. “The place of autonomy in bioethics.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 311.

Veatch, Robert M. “Abandoning Informed Consent.” Arguing About Bioethics. By Stephen Holland. London: Routeledge, 2012. 317-328.

http://www.cnn.com/2011/HEALTH/04/14/teens.circumcision.ep/index.html

http://www.cnn.com/2011/HEALTH/06/22/surgery.obese.teens/index.html

http://www.medicinenet.com/circumcision_the_medical_pros_and_cons/article.htm#what_has_been_the_medical_view_of_circumcision

In these decades, informed consent has been a significant medical issue. People still aren’t sure what kinds of actions to take in some cases. For example, should doctors respect the patients or the patients autonomy? Also how much information should the doctors provide their patients? These situations are really hard to deal with because there are many barriers to informed consent such as patients’ and doctors’ attitudes, medical system, and the information given for the decision making. In the following example, it shows a recent article that deals with informed consent.

On February 2, 2014, there there was a news called “Donor’s death shatters family, stuns surgeons” (www.bostonglobe.com). Paul Hawks, who was 56 years old, decided to donate some parts of his liver to his brother-in-law Tim Wilson, who had liver cancer. However, Paul died during the liver transplant. So what exactly happened in this case? Did the doctors and the patients make the right decisions? In the article, it mentioned that Paul was considered an older donor and was also examined to have extra blood vessels and abnormalities on his electrocardiogram. However, these situations didn’t change the hospital’s transplant team’s decision on this transplant. Instead, they decided to continue this case, because they were confident since the team had never failed any transplant. Even though in this article the reader couldn’t tell if the doctors actually told Paul and his family about his age and some problems he had, it mentioned that “When the donor is a child, parent, spouse, or sibling, the recipient’s survival is more obviously paramount to them — and the donor’s acceptance of risk therefore more understandable.” It seemed to me that the doctors assumed that the patient’s choice was rational because Tim was his relative. Since the doctors were so confident of their past record, it showed that the doctors didn’t inform the information (consequences) well enough to the patients in order for the patients to make a right decision. As Robert M. Veatch had written, “But even understanding is not enough. Facts must be assembled to tell a story or to construct an argument which stands in the foreground of deliberation” (Holland pg 334). Therefore in this case, the doctors probably didn’t deliver the information in a more constructed way. The doctors should have directed the Paul to think more about the transplant and the side effects of it.

This case also raises other questions such as should the donor be able to know the recipients’s risk factors and that the recipient should know that donors have some health problems that might cause transplant failure. By disclosing these information, it allows the donors and recipients to make better judgment and decisions. However, this also leads to another situation, which is privacy. By protecting privacy, the donors and the recipients lack some information to make appropriate decision. Therefore in this case, should we care more about the privacy or the outcomes of the decision.

Kowalczyk, Liz. “Donor’s Death Shatters Family, Stuns Surgeons.” Metro. BostonGlobal, 02 Feb. 2014. Web. 02 Mar. 2014.

To tie into Jackie Glodener’s post about autonomy and children, an extreme case about this topic became reality last week when Belgium granted the right to euthanasia for minors. The Parliament passed the law 86 to 44 with 12 abstentions. Back in 2002, the country legalized euthanasia for those in “constant and unbearable physical or mental suffering that cannot be alleviated” for adults and have since extended the law to include children.

The new bill gives the right only under strict conditions, which seem to fulfill Miller’s four senses of autonomy. A child psychologist or psychiatrist will examine the child’s capability of decision-making, which matches Miller’s idea that the patient is fully competent and aware of his or her decision and addresses previous apprehensions about autonomous decisions in children. The child must receive adequate information from the doctor and his or her parents about death itself. The parents also must give consent for the child’s decision. In addition, the bill protects the doctor’s opinion by stating that no doctor would be forced to carry out the act against his or her will. In all cases the child would have the option of palliative treatment.

While the law’s guidelines seem to adhere to the principle of respect for autonomy, there still seems to be something morally wrong and complex about the issue at hand.

An article about the bill can be found here: http://www.cnn.com/2014/02/13/world/europe/belgium-euthanasia-law-children/

Here is a related article I found, and wanted to share for providing an interesting read. I believe everyone in our class can benefit, as it places more context about a topic we are now all much better familiar with; paternalism, among others.

“While this is a welcome development, it should not obscure the fact that there is still a place for old-fashioned paternalism in medicine — though the decision to defy a patient’s wishes or withhold information is one of the trickiest that we doctors face.”

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.