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Medical Decision Making
Nuala Kenny SC, OC, MD, FRCPDepartment of Bioethics (post-rtd)Dalhousie University, Halifax, NS
Ethics & Health Policy AdvisorCatholic Health Association of CanadaOttawa, Ontario
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History Respect for autonomy Informed choice
Competence Third-party decisions
Models doctor-patient relationship Shared decision making
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History of Medical Decision-making
Hippocratic duty of beneficence Beneficence vs paternalism
Doctor as decision-maker
Modern bioethics
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The Traditional Practice
Doctor Decides
Patient Welfare
Peers/Profession
Direct PaymentCare by Families
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Modern Bioethics
Inclusion of many voices & perspectives in increasingly complex, value-laden decisions
Principle-based reasoning Respect for autonomy Beneficence Non-maleficence Justice
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Elements of Informed Choice:A Tool for Respecting Autonomy
Information Reasonable patient standard Truthfulness vs disclosure
Capacity/competence
Freedom, voluntariness From coercion; from undue fear and
from guilt
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Competence
Capacity to indicate a choice
Understanding relevant information
Making a ‘reasonable’ decision
Using rational reasons to reach a decision
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Differences re Competence
In Law Here & now decision Presumed Understand the choice & gives reasons
In Medicine Whole person Tested (protected) Understand nature of choice,
consequences and alternatives
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Advance Directive:Continuation of Respect for Autonomy
Advance care planning includes a directiveA document made by someone while capable concerning health care decisions to be made in the event that the person becomes incapable to make such decisions in the future Instructional directive (‘living will’)-what or how
health care decisions are to be made Proxy directive -who is to make health care
decisions
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3rd Party Decisions
The patient must be incompetent Fluctuating, deteriorating
Information, capacity, freedom A decision must be made The decision must be made as the
patient would want using: Substituted judgment Best interest
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Models of the Doctor-Patient Relationship
The paternalistic model
The informative model
The interpretive model
The deliberative model Emanuel & Emanuel
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Issues Determining the Doctor-Patient Relationship
The goals of medicine Physician’s obligations Patient values The understanding of patient
autonomy
Emanuel & Emanuel
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The End of Medicine
The end of medicine is a right and good healing action
E Pelegrino The Philosophical Basis of Medicine
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Some Deeply Problematic Issues
The doctor’s duty to do no more intentional harm than benefit
Confusion regarding “respect for autonomy” of the patient
Confusion re the goals of medicine The problem of futility
Quantitative vs qualitative “Best interest” in a consumer world
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Shared Decisions-The Ideal
The doctor’s role is to provide facts about the disease, prognosis & possible treatments (based on evidence of benefit vs risks/harms)
The patient’s role is to provide the values-conception of the good-to evaluate and then select among the options
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Difficulties with Division of Roles(Dan Brock)
Doctors’ information as value-neutral
Patients’ values are incorrigible i.e. cannot be mistaken
Assumption that patient values are correct and physician must act on them
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When Sharing Breaks Down
Unilateral declarations by the doctor Demands for non-validated and non
recommended treatments by patients; litigation
The crucial need for respectful communication
Inevitable distress and compromise of patient welfare
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The End of Medicine
The end of medicine is a right and good healing action
E Pelegrino The Philosophical Basis of Medicine
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