Chapter Seven

Autonomy vs. Paternalism:

A Contest Between Virtues
“Who Is The Patient?”
 Considerthe “Who Is the Patient” case
study that begins the chapter
 Should the physician write the
prescription?
 What system (duty, consequence, virtue,
divine command reasoning) did you use
to make the decision?
 What basic principles did you consider?
 The Case for
Paternalism
 Actingin a way believed to protect and
advance the interests of another,
although actions may be against the
other’s desires
 We have more information than the
patient (trust me, I’m a doctor!)
 They came to us to help them
 No one rational chooses bad health
Paternalism
 Historically,
health care has moved
from paternalism toward patient
autonomy
 Paternalism does not necessarily equal
abusive power. In its best sense it is a
confict between two basic principles:
 Autonomy
 Benefcence
Health –
the Universal Good
 Health is often considered a universal
good. It is, however, not always our
highest priority.
 If health were our priority, following
good health care advice would always
be the best policy.
 Health – the Universal
Good (continued)
 Healthcare decisions are not only
matters of medical expertise but also of
individual value preference
 Autonomy vs. Paternalism
 Professional autonomy.
 Does patient’s desire for less than optimal
care trump practitioner’s desire to provide
the best care possible?
 Can practitioner refuse to treat a non-
compliant patient? Problem of
abandonment.
 Proposed Provider-Patient
Relationship Models
 Whichof these models best fts the
current patient-provider relationship?
 Engineering
 Priest
 Collegial
 Contractual
Informed Consent
 Essential elements:
 Disclosure
 Understanding
 Voluntariness
 Competence
 Consent
 Does
autonomy include a right not to
know?
 Informed Consent
(continued)
 Consent can take many forms:
 Oral
 Written
 General
 Special
 Implied
 Evolution of
Disclosure Standards
 Disclosure standards:
 Professional community standard
 Reasonable patient standard
 Patient-centered standard
 Which is the current legal standard?
 Which is perhaps the most ethical
standard?
 Competency
Determination
 Does the patient understand the nature
of the illness, and the consequences of
the various options that may be chosen?
 Is the decision based on rational
reasoning or protected under First
Amendment?
 Competency Determination
(continued)
 Competent adults have an absolute
right to refuse medical treatment even if
the refusal is life-threatening
 Autonomy vs. Paternalism
(case problem)
A pregnant female is brought to
the emergency room, bleeding
profusely, needing a transfusion to
save her life and that of the fetus
As a Jehovah’s Witness, she refuses
the transfusion
 Does she also speak for the fetus?
 Is there a limit to her autonomy?
Protection of Children
 The courts have generally held:
 Parents may refuse care for themselves
for religious beliefs
 They may not make choice for children
 Prior to the age of full and legal
discretion, neither parents nor the child
make the choice
 Guardian ad litem
Demand for Futile Care
 Helga Wangele and Baby K:
 In both cases, the courts held that care
beyond palliative measures should be
provided, even in situations that health
providers deemed to be futile
 Isthis equal to the oft heard “The
customer is always right”?
Emergency Medical Treatment
and Labor Act (EMTALA)
 Hospitals must:
 Provide medical screening for all patients
who seek emergency care
 Stabilize patient’s condition
 Maintain an accurate on-call physician
directory
 Provide medically appropriate transfers
 APACHE Scoring
System
 Review Exercise F in review exercises
 Do these evaluation systems provide an
answer to the request for futile care
conficts?
 Would you fnd the current level of
accuracy acceptable?
 If not, what level would you demand?
 Autonomy Reconsidered
 Havewe moved too far in support of
autonomy?
 The demand for futile care?
 The right of pregnant women to refuse
AIDS testing?
 The right for mentally incompetent
homeless to stay on the streets in
inclement weather?
Key Concepts
 Modern health care has moved away
from the principle of paternalism and
toward honoring patient autonomy
 Competent adult patients are accorded
the right to make the signifcant
decision in regard to their personal
health care
Key Concepts (continued)
 Competent adults have the right to
refuse medical treatments, even in life-
threatening situations
Key Concepts (continued)
 Competency is granted following the
affirmation of the following:
 Patient understands nature of illness and
consequences of options available
 Decision is based on rational reasoning
 If decision based on faith, is it entitled to
First Amendment protection under the
Constitution?
Key Concepts (continued)
 Demand for futile care:
 The courts have in general found for the
patient and family in cases where the
disagreement seems to be a matter of
health provider-patient value diferences
in goal outcomes
 Helga Wangele case
 Baby K case