Tag Archives: informed consent

The “When” of Libertarian Paternalism

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The reading on “Libertarian Paternalism” takes a concept that has for years been seen in a negative light and gives it a positive spin (Thaler and Sunstein). When discussing the history of health care and public health in America especially, the concept of paternalism is typically thrown around in tones of disgust and shame. Authority figures in the realm of health aren’t qualified to decide what is best for us—only we are capable of making those decisions.

In our discussions surrounding informed consent and autonomy, we continuously mulled over whether or not health care professionals have the right to make decisions or even narrow down treatment options for patients. I have come to the conclusion that they largely do have this authority and duty. Though the model of the doctor/patient relationship could use some serious work, patients do not need to know about each option available to them; being informed is important, but doctors are capable of narrowing down treatment options without full patient partnership.

Thaler and Sunstein take this question of the morality of paternalism to a different level. They use examples of a less immediate nature such as retirement plans and cafeteria layouts to illustrate the unavoidable nature of paternalism and just how beneficial it can be, suggesting that we not focus on whether or not paternalism is right in certain cases but how to choose the best paternalistic options.

Though the examples they use are simple, I believe Thaler and Sunstein have a point regarding paternalism in public health. People will most often do what is best for themselves. Public health is the improvement and maintenance of the health of communities, not the individual—thus it is not beneficial to rely upon individuals to make effective decisions in public health.

What is interesting to me, though, is that this argument can then stand as a counterargument in the informed consent and autonomy debate. If individuals do what is in their own interests, isn’t it then moral to leave health care decisions fully up to them? It would seem that if one asked Thaler and Sunstein, the answer would be yes. However, although I am convinced of their argument for paternalism in public health, I believe libertarian paternalism can also be applied to treatment decisions in health care.

Individuals are—to an extent—capable of deciding what is best for them; but in the realm of health care, there is a lot of knowledge that professionals have access to that the average person does not. Even with thorough information—it is difficult for patients to make these sometimes life altering decisions. What is so wrong with a little libertarian paternalism? As Thaler and Sunstein mention in their essay, in everyday situations in which this type of paternalism is used, it is because the people do not want to undergo the hassle of making an initial decision themselves, or they feel as though they are not specialized enough in the matter to make the appropriate decision on their own.

Though I have never before viewed paternalism positively, I believe this essay makes a sound argument for it. This does not mean that paternalism is good; it just means that there are several situations in which it is conducive to efficiency and genuine well-being which should make it acceptable.

Thaler, Richard H., and Cass R. Sunstein. “Libertarian Paternalism.” Arguing About Bioethics (2003): loc.  10829-10968. Print.

Teaching Compassion….Can it be done?

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This summer I studied abroad in Italy, and in six weeks, I traveled to over 40 cities. We didn’t have a traditional classroom setting for the streets of Rome, the museums of Pisa, the temple of Agrigento (in Sicily), and even the seats of our bus, winding through the Tuscan hills, served as our classroom.

rome Tower of Pisa, Italy. agrigento

One of the two courses we took was called Medicine and Compassion, and our professors were from the CDC and Emory Medical School. I thought our professor must be “science people” and we would just talk about medicine because what could you teach about compassion other than to have it?

Looking back, I laugh at my former self for my naivety. In this class, we read a few books, several short stories, and many articles that highlight compassion, empathy, communication, and ethical dilemmas. We were constantly asked, “what is compassion?” I began in Rome thinking compassion was feeling bad and being nice to a person who was dealing with a difficult thing and trying to put myself in their shoes. Wait isn’t that empathy thought? I was very confused and continued to be. My definition changed weekly with new insight gained and old preconceived notions lost. By the end of the program, my definition of compassion included the ability to connect at a personal level despite not having been in their situation and being able to communicate with them so that they could understand me and I could understand them.

You may think, “What does compassion have to do with informed consent?” Don’t worry; I’m getting there! Informed consent relies on physicians educating their patients and explaining what is wrong with them, the risk of a procedure, or their prognosis. In the article “Should informed consent be based on rational beliefs?” the author states “physicians duties as educators are more extensive … physicians must be prepared to do more than provided patients with information relevant to making evaluative choices. They must attend to how that information is received, understood, and used”.

I used to, and I am sure many physician still today, believe that you just need to tell the patients the facts. What could be so hard to understand? It is very easy for people to forget that not everyone knows or comprehends their field, and this is particularly true in medicine. Furthermore, physicians and other professionals alike are at the top tier of the education spectrum and there are many patients who did not go to college or even graduate high school. Those patients ability to understand medical terminology and the implications of treatments is much more limited. Thus, it requires the physician to have compassion and educate the patients to obtain true and complete informed consent.

Below is a link to an article in the New York Times called “Can Doctors Be Taught How to Talk to Patients?” I think this article, like my study abroad program, demonstrates the medical communities recognition and refocusing on the doctor-patient relationship and what exactly that should entail. According to the NY Times article “after all, [doctors] admission to medical school was not based on a validated assessment of their ability to relate to other human beings.”

http://well.blogs.nytimes.com/2014/02/27/can-doctors-be-taught-how-to-talk-to-patients/?_php=true&_type=blogs&src=me&_r=0

References:

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

Reforming Informed Consent

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Robert M. Veatch’s article argues that informed consent should be abandoned due to its uses as a “transitional concept” and ambiguity (Veatch 317). Veatch provides several examples to support his argument, among these include the “best interest standard”, how a person defines well-being, and physician bias (322-334). All of Veatch’s examples are accurate; with our current health care system it is difficult for physicians to make recommendations or conduct procedures on patients. Two important supporting facts of Veatch’s argument are that “actual consent is not obtained in all cases” and that the concept of informed consent is a relatively recent occurrence (317-318). Patients may also misinterpret the benefits and risks of a procedure (Krumholz 1190). However, in present day Western society I do not think that we would be able to eliminate informed consent. There are too many legal ramifications that could occur which will only require unnecessary spending. In order to find a median between informed consent and the best interest of the patient I suggest that the physician-patient relationship be adapted.

Many of the information against consent were rooted in the physician-patient relationship. American health care does not place great emphasis on time spent with the patient, which does not allow physicians to get to actually know their patients. Many of the issues Veatch present deal with this lack of relationship. This suggests that improving and strengthening the relationship between the two parties would be beneficial for both.

An article by Dr. Harlan M. Krumholz poses a potential solution to improving the consent process. Dr. Krumholz suggests a patient centered approach. Patient centered care focuses on “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (Krumholz 1190).  This means that the physician must have a minimal understanding of who their patient actually is. By acknowledging and working with the patient based on their values, many of the issues that Veatch brings up become irrelevant. To improve patient knowledge about procedures and to improve the process of giving consent Krumholz suggests that patients should receive a “brief standardized and personalized informed consent document” that would cover the risks, benefits, alternatives, experience and cost of the procedure (1190).  This document can facilitate discussion between physician and patient, and allow the patient to ask more questions and receive the doctor’s opinion. Consent forms will be standardized, and be at an average reading level and reasonable length (Krumholz 1190). Consent forms will not be written by the institution but by experts from the Department of Health and Human Services. One health system in Kansas City has tried out Krumholz’s solution, which led to “improved reading and satisfaction with the consent process, less patient anxiety, and a sense of partnership in the decision-making process” (1190). Krumholz’s solution agrees with one of the last points of Veatch’s article, “the concept of consent will have to be replaced with…active patient participation” (Veatch 327).

This change to patient-centered care could be added to current health care reform. President Obama’s Patient Protection and Affordable Care Act is attempting to improve health care by reducing the amount spent on health care and providing quality care that is affordable (Health Care Reform Timeline). Including active patient participation into the reform (or as a result of it) can also be beneficial. People may take a greater interest in their health, and could be more proactive in maintaining healthy lifestyles.

Sources

Health Care Reform Timeline. http://obamacarefacts.com/health-care-reform-timeline.php

Krumholz, H.M. “Informed Consent to Promote Patient-Centered Care.”  JAMA. 303.12 (2010):1190-1191. Web. 24 Feb 2014.

Veatch, R.M. Arguing about Bioethics. Ed. Stephen Holland. Routledge: New York, NY, 2012. Print.

(Mis) Informed Consent: A Doctor’s Perspective

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Prior to having read some of assigned essays on informed consent, I believed it to be a relatively cut and dry issue. Many of the articles or videos that I have reviewed on informed consent seem for the most part repetitive. Informed consent is important—a good thing. Without policies that detail protocol doctors must follow in regards to their treatment of patients, who knows how a patient may be taken advantage of? After all “doctor knows best”; if the law does not stand to protect the rights of patient, who will? Should a patient be of sound mind and of age, they should be given full disclosure regarding the purpose of a medical procedure, the risks and benefits, probability of risk as well as alternatives to treatment (Brody, 283).  I am not a doctor and thus am only able to see things from the patient’s side of the informed consent debate. It seems simple, really. For a physician to balk at the idea of thoroughly briefing and obtaining permission regarding what happens to their patients’ bodies is ridiculous, right?

If informed consent is so great, though, why do so many physicians see it in many cases as unnecessary or frivolous? In the process of searching for interesting essays or articles on informed consent from a physician’s perspective, I stumbled upon a brief opinion piece by John Kelly IV, an MD who is a regular writer for Outpatient Surgery Magazine. Although the opinion was humorous, I think it did a decent job of shedding light onto the ways in which informed consent may be good in theory, but not in practice. Two of the problems that he focuses on in particular are “nitpicking” and “catastrophizing” (Kelly). The consent form is a legal document and of course important; however, how explicit do they really need to be? It is one thing to list possible risks for a certain procedure—that is for the patient’s benefit. But how detailed does a doctor need to be in describing a surgery that is a part of their daily routine? Forcing doctors to stress and go back over every word in a consent form is a waste of time and if anything, could cause them to lose respect for and patience in the process of informed consent.

The major issue that doctors seem to be concerned about when it comes to informed consent based upon my and other students’ posts seems to be “catastrophizing”: the idea that being too explicit in the risks of procedures, some of which are incredibly low, can lead to discouraging patients to receive the treatment and care that is essential to their health (Kelly). How much information is too much?

I am not at all saying that the cons of informed consent outweigh autonomy, which is the moral issue at the center of the argument. I do, however, believe that there should be a movement to standardize policy across states to make the issue a little less hazy for all involved as well as help to maximize the use of doctors’ time.  Solutions that I can think of include an official electronic database on which the risks of various standard procedures are outlined so that patients can clearly view the costs and benefits prior to giving consent. Another option would be to hire hospital staff or train current staff to specialize in patient relations; people who can to sit down with individuals and talk them through the risks and alternatives, as well as their doctor’s recommendations.  I am not sure what other solutions have been proposed or initiated; but until a larger solution is settled upon, the autonomy of the patient will continue to trump physician convenience and efficiency, and rightly so.

Citations:

Brody, Baruch A., and H. Tristram. Engelhardt. “Adult Patients: General Issues.” Bioethics: Readings Cases. Englewood Cliffs N.J: Prentice-Hall, 1987. 282-86. Print.

Kelly, John, IV. “Cutting Remarks: (Mis) Informed Consent.” Outpatient Surgery Magazine. N.p., Feb. 2014. Web. 17 Feb. 2014. <http://www.outpatientsurgery.net/outpatient-surgery-news-and-trends/humor-and-jokes/cutting-remarks-mis-informed-consent–02-14>.

Canterbury v. Spence

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The opinion in Canterbury v. Spence provides a great opportunity for discourse on the patient’s right to informed consent, which sometimes opposes what the physician may think is best for their patient.  Just as soon as there is a rule regarding guidelines to informed consent, there is bound to be an exception to that rule.

 

As this case so clearly demonstrates, it is far from uncommon for a physician to be sued for malpractice in the event that something has gone wrong.  Because of this constant threat, one might think that doctors would be completely on board with informing their patient as thoroughly as possible, if only to prevent cases like Canterbury v. Spence from happening.  While ideally the fear of malpractice suits should not be the only factor motivating physicians to fully inform their patients, it may be a good starting point.

 

While Dr. Spence claims to have withheld the information because he had the patient’s wellness in mind, it seems reasonable that Canterbury may have been better served by being completely informed.  When a minute but potentially significant risk is involved, it may be better to over share, especially if the patient is of sound mind, as Canterbury allegedly was.  At that point, the patient has all the cards in his hand and makes a fully informed decision. This would also bring into account the relationship between the patient and physician. Ideally, the physician would be able to inform the patient of all potential risks and still trust that the patient would have enough faith in the physician’s educated opinion on what the course of action should be, as the doctor is clearly more well-versed on current medical practice.

 

An interesting point that O’neill brings up in his article “Some Limits of Informed Consent,” is how problematic informed consent can become when relating to issues of public health policy.  The examples he gives are those of water purity levels and food safety requirements.  It is simply not feasible to adjust these levels or regulations to individual choice, and it is unreasonable to assume that each individual would have the knowledge necessary to make a decision like that. The reason we have professionals who devote their lives to this field of study is for precisely that reason, and for the most part, we do well in trusting their expertise.

 

 

Bibliography

O’neill, O. “Some Limits of Informed Consent.” Journal of Medical Ethics 29.1 (2003): 4-7. Print.

 

The Limits of Informed Consent

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The autonomy of the patient has triumphed, in legal terms at least. Doctors and health care personnel are legally required to disclose information about treatments to patients, and patients have the legal right to say “yes” or “no” to any treatment. But how practical is informed consent? The legal implementation of informed consent seems to be mostly a matter of filling out extra paperwork. So that seems practical enough. On the other hand, actually practicing the moral values behind informed consent is much more difficult.

We value the freedom to choose on so many levels. We have a right to choose as consumers, as voters, as citizens and as competent people in general – so then why not as patients? Of course patients should have a right to consider multiple opinions, assess alternative treatments, and then make a choice on their own. But in reality, a patient’s autonomy is highly limited. A lot of the limiting factors are neither inconsequential nor easily avoidable. In Barriers to informed consent, Lidz et al. outline how patient trust, physician expertise, acute illnesses, and complex medical systems make true informed consent difficult to achieve.

Are we morally obligated to try to overcome these obstacles? Or can they be viewed as the practical, real-world limits to our abstract ideals of patient autonomy? This question isn’t really about obstacles like access to healthcare or the complexity of the healthcare system. There’s no question that we should be trying to increase access to care and streamlining the system. The interesting obstacles are those that deal with the doctor-patient relationship. Should we be trying to change this relationship on a moral basis?

Let’s consider patient trust and physician expertise – both important obstacles to informed consent. Patients often don’t really want to make a decision based on what they know about their medical condition. They instead trust the physician enough to make such decisions for them. I see this as a clear act of autonomy. It’s a very rational choice to trust a trained professional’s informed decision over one’s own, likely less-informed decision. Ah but that’s where physicians have to make sure patients are fully and objectively informed, right?  Well even if a physician explains the relevant diagnosis and treatment to the patient in an easily comprehendible way, most patients will not know the essential mechanisms and pathology behind the physician’s decision. They’ll instead be given a simplified picture of a complex system – one that is inevitably going to be biased towards the physician’s decision anyway. We can’t blame physicians for such simplified, biased explanations any more than we can blame scientists for being biased towards one particular theory or paradigm. In the words of Galileo, “it is not within the power of the practitioners of demonstrative sciences to change opinion at will,” (p 125). They are compelled to believe what they believe by the power of reason.

All of this is not to say that the “informed” part of informed consent is irrelevant just because it is likely to have a bias. But maybe the information is, for practical considerations, less important than what we call patient trust – a form of rational consent.

Sources:

Galilei, Galileo, and Maurice A. Finocchiaro. The Essential Galileo. Indianapolis, IN: Hackett Pub., 2008. Print.

Charles W. Lidz, Ph.D., Alan Meisel, J.D., Marian Osterweis, Ph.D., Janice L. Holden, R.N., John H. Marx, Ph.D. and Mark R. Munetz, M.D. “Barriers to Informed Consent.” Arguing About Bioethics. Ed. Stephen Holland. London: Routledge, 2012. 93-104. Print.