Transcript Autonomy and Competence and Capacity to make

Dr Idara C. Eshiet
This is a basic fundamental human right.
It is the most fundamental principle underlying
all health-care ethics.
This is the patient’s right to make their own
decisions concerning their healthcare after
being properly educated and informed.( see
American College of Physicians Ethics Manual
, 2,15).
In a health care setting, the principle of Autonomy
translates into the principle of informed consent:
You shall not treat a patient without the
informed consent of the patient or his or her
lawful surrogate, except in narrowly defined
exceptions.
In order to affirm autonomy, the physician has to
make every effort to discuss treatment
preferences with patients and ensure that they
are documented in the patients’ charts.
It is the responsibility of the physician to always act
in the best interest of the patient.
This requires us to do good, or what will further the
patient’s best interest.
The following secondary principles come under
Beneficence:
a. Prevent infliction of needless pain
b. Prevent killing
c. Prevent incapacitating others.
This requires us, other things being equal ; to avoid
harming the patient, or what would be against the
patient’s interest.
The following secondary principles come under nonmaleficence:
a. Do not kill
b. Do not cause needless pain
c. Do not incapacitate others ( Beaucamp and
Childress)
Note that these principles can be met by doing
nothing.
In summary, the principle of beneficence means
that unless there is sufficient reason not to, one
has an obligation to do those acts that are likely
to do more good than harm.
The principle of non-maleficence means that unless
there is a sufficient reason not to, one has an
obligation not to do those acts that are likely to
produce more harm than good.
This means acting without a person’s consent or
overriding a person’s wishes, wants, or actions, in
order to benefit the patient or prevent harm to
him or her.
Paternalism overrides a competent patient's
explicit wishes , and is generally rejected because
it violates autonomy; falsely presumes
independent knowledge of what is best for the
patient; and falsely presupposes that there is a
clear, objective set of values governing such
decisions. ( AMA code, 8.08)
A woman enters the emergency room with stomach pain. She
undergoes a CT scan and is diagnosed with an abdominal aortic
aneurysm, a weakening in the wall of the aorta which causes it
to stretch and bulge (this is very similar to what led to John
Ritter's death). The physicians inform her that the only way to
fix the problem is surgically, and that the chances of survival
are about 50/50. They also inform her that time is of the
essence, and that should the aneurysm burst, she would be
dead in a few short minutes. The woman is an erotic dancer;
she worries that the surgery will leave a scar that will negatively
affect her work; therefore, she refuses any surgical treatment.
Even after much pressuring from the physicians, she adamantly
refuses surgery. Feeling that the woman is not in her correct
state of mind and knowing that time is of the essence, the
surgeons decide to perform the procedure without consent.
They anesthetize her and surgically repair the aneurysm. She
survives, and sues the hospital for millions of dollars
Competence is a legal term
Only a court can determine that a patient is
incompetent.
All adult patients are deemed competent unless
specifically proven otherwise.
Physicians can determine whether or not a
patient has the capacity to understand his / her
medical condition.
The physician determines the capacity of the
patient to comprehend his/ her medical
problems based on whether there is an
organic delirium due to a medical condition
such as an electrolyte imbalance, hypoxia,
drug intoxication, meningitis, encephalitis, or
a psychiatric disorder.
This is done largely based on a neurological
examination testing memory,
comprehension, reasoning, and judgment.
Conditions for competence
• The patient must be able to comprehend
information and is able to know that he or she is
authorizing medical treatment , is able to
understand the effects of treatment, options in
terms of health, life, lifestyle, religious beliefs,
values, family and all other factors bearing on
treatment decisions.
• The relevant competence is competence to
make the specific treatment decision at hand.
A minor is said to be someone under 18 years.
Minors are not considered competent to make
decisions concerning their healthcare.
Only a parent or a legal guardian can give
consent for a minor.
Note: In emergency situations, consent in
implied.
The neighbor of a 14- year old boy brings him to the emergency
department after sustaining a laceration to the scalp from head
trauma. You evaluate him and determine that suturing of the
scalp will be necessary.
Which of the following is the most accurate?
a. He is an emancipated minor; the patient can give consent
b. The neighbor can give consent
c. Wait for the consent of at least one parent
d. Wait for the consent of both parents
e. Consent is not necessary in this case
Although parents and guardians can give
consent for procedures and therapies for
minors, there are certain exceptions to this
rule.
In areas of :
1. Prenatal care
2. Contraception
3. Sexually transmitted diseases
4. Substance abuse
A 15- year old girl comes to the clinic for dyspareunia
and a vaginal discharge. On speculum examination
you find she has cervicitis. The pregnancy test is
negative. The infection is modest and there is no
emergency. What is the appropriate action to take?
a. Ceftriaxone/ azithromycin now in a single dose
b. Make at least a “ good faith” effort to notify her
parents and treat her
c. Wait to inform at least one parent
d. Treat only if the patient agrees to inform her parents
e. Treat her now and inform the parents later.
A 16- year old female comes to the clinic after missing a
period. Her pregnancy test is positive and she wants
to start prenatal care with you. She is adamant that
you keep the pregnancy confidential from her
parents.
What should you tell her?
a. “ I will give you the care you need and keep it
confidential”.
b. ” I will not mention it to your parents unless they
ask. I can’t lie”.
c. “ I am sorry, but I must tell them”.
d. “ I will not tell your parents, but I must inform the
father of the baby”.
A small number of minors, mostly at older ages
such as 16 or 17, may be considered
‘emancipated’ or freed from the need to have
parental consent for medical care.
Criteria:
1. Married
2. Self- supporting
3. Living independently
4. In the military
5. Parent of a child they themselves support.
1.The physician must consult the patient’s living
will if there is one
2. If there is no living will or the living will provides
no clear guidance, the physician must consult
the surrogate decision maker: either one
designated by a durable power of attorney, or a
family member.
In order of priority: healthcare durable power of
attorney, or guardian; spouse; children of legal
age; other relative, close friend , or caregiver.
1. Principles of medical Ethics by Beauchamp
and Childress 7th Edition
2. Resolving Ethical Dilemmas Bernard Lo 5th
Edition
3. American Medical Association code of
Medical Ethics, 1996