“Informed consent” is a legal instrument that allows individuals to define their own interests and to protect their bodily privacy. In current medical practice, patients who have consented to surgery are considered to have implied consent to anaesthesia, even though anaesthesia is associated with its own particular set of risks and consequences that are quite separate from those associated with surgery. In addition, anaesthetists often perform interventions that are the only medical treatment received by a patient. Anaesthetists, therefore, should always (...) obtain separate consent for anaesthesia, and should regard the process of consent as a stimulus for active, fluid reciprocal discussion with patients about treatment options. (shrink)

This article discusses the response of our ethics consultation service to an exceptional request by a patient to have his implantable cardioverter defibrillator removed. Despite assurances that the device had saved his life on at least two occasions, and cautions that without it he would almost certainly suffer a potentially lethal cardiac event within 2 years, the patient would not be swayed. Although the patient was judged to be competent, our protracted consultation process lasted more than 8 months as we (...) consulted, argued with, and otherwise cajoled him to change his mind, all to no avail. Justifying our at times aggressive paternalistic intervention helped us to reflect on the nature of autonomy and the dynamics of the legal, moral, and personal relationships in the clinical decision-making process. (shrink)

Contemporary clinical ethics was founded on principlism, and the four principles: respect for autonomy, nonmaleficence, beneficence and justice, remain dominant in medical ethics discourse and practice. These principles are held to be expansive enough to provide the basis for the ethical practice of medicine across cultures. Although principlism remains subject to critique and revision, the four-principle model continues to be taught and applied across the world. As the practice of medicine globalizes, it remains critical to examine the extent to which (...) both the four-principle framework, and individual principles among the four, suffice patients and practitioners in different social and cultural contexts. Using the four-principle model we analyze two accounts of surrogate decision making – one from the developed and one from the developing world – in which the clinician undertakes medical decision-making with apparently little input from the patient and/or family. The purpose of this analysis is to highlight challenges in assessing ethical behaviour according to the principlist model. We next describe cultural expectations and mores that inform both patient and clinician behaviors in these scenarios in order to argue that the principle of respect for persons informed by culture-specific ideas of personhood may offer an improved ethical construct for analyzing and guiding medical practice in a globalized and plural world. (shrink)

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico-legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. The terrain (...) can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority. (shrink)

BackgroundPatient autonomy is a fundamental, yet challenging, principle of professional medical ethics. The idea that individual patients should have the freedom to make choices about their lives, including medical matters, has become increasingly prominent in current literature. However, this has not always been the case, especially in communist countries where paternalistic attitudes have been interwoven into all relationships including medical ones. Patients’ expectations and the role of the doctor in the patient-physician relationship are changing. Croatia, as a transitional country, is (...) currently undergoing this particular process.MethodsQualitative research was conducted by means of six focus group discussions held in the years 2012 and 2013 in Croatia. Focus groups were held separately with each of the following: first year and final year medical students, physicians engaged in medical ethics education, physicians practicing in a clinical hospital, family medicine residents and individuals representing patients with chronic disease. This research specifically addresses issues related to patient autonomy, in particular, the principles of truth telling, confidentiality, and informed consent. All focus group discussions were audio taped and then transcribed verbatim and systematized according to acknowledged qualitative analysis methods.Results and discussionPatient autonomy is much more than a simple notion defined as the patient’s right to make treatment decisions independently. It has to be understood in context of the broader socio-cultural setting. At present, both patients and medical doctors in Croatia are increasingly appreciating the importance of promoting the principle of autonomy in medical decision-making. However, the current views of medical students, physicians and patients reveal inconsistencies.Conclusions Knowing how to respect the various facets of patients’ autonomy should be part of physician’s professional duties, and also be reflected in his or her core clinical competencies. For this reason greater importance should be dedicated to patient autonomy issues in medical education in Croatia. (shrink)

This article highlights the limitations of the tendency to frame health- and wellbeing-related digital tools (mHealth technologies) as empowering devices, especially as they play an increasingly important role in the National Health Service (NHS) in the UK. It argues that mHealth technologies should instead be framed as digital companions. This shift from empowerment to companionship is advocated by showing the conceptual, ethical, and methodological issues challenging the narrative of empowerment, and by arguing that such challenges, as well as the risk (...) of medical paternalism, can be overcome by focusing on the potential for mHealth tools to mediate the relationship between recipients of clinical advice and givers of clinical advice, in ways that allow for contextual flexibility in the balance between patiency and agency. The article concludes by stressing that reframing the narrative cannot be the only means for avoiding harm caused to the NHS as a healthcare system by the introduction of mHealth tools. Future discussion will be needed on the overarching role of responsible design. (shrink)

Autonomy has been hailed as the foremost principle of bioethics, and yet patients’ decisions and research subjects’ voluntary participation are being subjected to frequent restrictions. It has been argued that patient care is best served by a limited form of paternalism because the doctor is better qualified to take critical decisions than the patient, who is distracted by illness. The revival of paternalism is unwarranted on two grounds: firstly, because prejudging that the sick are not fully autonomous is a biased (...) and unsubstantial view; secondly, because the technical knowledge of healthcare professionals does not include the ethical qualifications and prerogative to decide for others.Clinical research settings are even more prone to erode subjects’ autonomy than clinical settings because of the tendency and temptation to resort to such practices as shading the truth when consent to participation is sought, or waiving consent altogether when research is done in emergency settings.Instead of supporting such dubious practices with unconvincing arguments, it would seem to be the task of bioethics to insist on reinforcing autonomy. (shrink)

In the face of mounting criticism against advance directives, we describe how a novel, computer-based decision aid addresses some of these important concerns. This decision aid, Making Your Wishes Known: Planning Your Medical Future , translates an individual's values and goals into a meaningful advance directive that explicitly reflects their healthcare wishes and outlines a plan for how they wish to be treated. It does this by (1) educating users about advance care planning; (2) helping individuals identify, clarify, and prioritize (...) factors that influence their decision-making about future medical conditions; (3) explaining common end-of-life medical conditions and life-sustaining treatment; (4) helping users articulate a coherent set of wishes with regard to advance care planning—in the form of an advance directive readily interpretable by physicians; and (5) helping individuals both choose a spokesperson, and prepare to engage family, friends, and health care providers in discussions about advance care planning. (shrink)

Background Paternalism/overprotection limits communication between healthcare professionals and patients and does not promote shared therapeutic decision-making. In the global north, communication patterns have been regulated to promote autonomy, whereas in the global south, they reflect the physician’s personal choices. The goal of this study was to contribute to knowledge on the communication patterns used in clinical practice in Mexico and to identify the determinants that favour a doctor–patient relationship characterized by low paternalism/autonomy. Methods A self-report study on communication patterns in (...) a sample of 761 mental healthcare professionals in Central and Western Mexico was conducted. Multiple ordinal logistic regression models were used to analyse paternalism and associated factors. Results A high prevalence of paternalism was observed among mental health professionals in Mexico. The main determinants of low paternalism/autonomy were medical specialty and gender, with female physicians being more likely to explicitly share diagnoses and therapeutic strategies with patients and their families. A pattern of highly explicit communication was strongly associated with low paternalism/autonomy. Finally, a modifying effect of age strata on the association between communication pattern or specialty and low paternalism/autonomy was observed. Conclusions Among mental health professionals in Mexico, high paternalism prevailed. Gender, specialty, and a pattern of open communication were closely associated with low paternalism/autonomy. Strengthening health professionals’ competencies and promoting explicit communication could contribute to the transition towards more autonomist communication in clinical practice in Mexico. The ethical implications will need to be resolved in the near future. (shrink)

ZusammenfassungOnora O’Neill hat 1984 den Zusammenhang zwischen grundsätzlichen Bedenken gegenüber dem ethischen Autonomiebegriff und der Kritik an der paternalistisch geprägten medizinethischen Praxis hergestellt, nicht die tatsächliche Einwilligung des konkreten Patienten zu berücksichtigen, sondern die angenommene, hypothetische Einwilligung, die ein idealisierter, völlig rationaler Patient geben würde. Im Anschluss an experimentalpsychologische Studien zur subliminalen Wahrnehmung, zu Volition und Handlungskontrolle erfahren kompatibilistische Theorien menschlicher Freiheit innerhalb der theoretischen Philosophie neue Popularität. Eine Handlung ist demnach frei, wenn sie das Resultat bestimmter Fähigkeiten einer Person (...) ist („Kompetenztheorie“). Der Artikel setzt sich mit zwei dieser Theorien, Henrik Walters Konzept „natürlicher Freiheit“ und Michael Pauens „Minimalkonzeption personaler Freiheit“ näher auseinander—und zwar vorderhand im Hinblick auf den Entwurf eines nichtidealisierten ethischen Autonomiekonzeptes. Als solches ist es an der aktualen bzw. faktischen Fähigkeit einer Person ausgerichtet, rekurrierend auf die spezifische Determiniertheit autonomer Entscheidungen und Handlungen sowie auf ein relativiertes Konzept menschlicher Vernunft. (shrink)

Onora O’Neill hat 1984 den Zusammenhang zwischen grundsätzlichen Bedenken gegenüber dem ethischen Autonomiebegriff und der Kritik an der paternalistisch geprägten medizinethischen Praxis hergestellt, nicht die tatsächliche Einwilligung des konkreten Patienten zu berücksichtigen, sondern die angenommene, hypothetische Einwilligung, die ein idealisierter, völlig rationaler Patient geben würde. Im Anschluss an experimentalpsychologische Studien zur subliminalen Wahrnehmung, zu Volition und Handlungskontrolle erfahren kompatibilistische Theorien menschlicher Freiheit innerhalb der theoretischen Philosophie neue Popularität. Eine Handlung ist demnach frei, wenn sie das Resultat bestimmter Fähigkeiten einer Person (...) ist („Kompetenztheorie“). Der Artikel setzt sich mit zwei dieser Theorien, Henrik Walters Konzept „natürlicher Freiheit“ und Michael Pauens „Minimalkonzeption personaler Freiheit“ näher auseinander—und zwar vorderhand im Hinblick auf den Entwurf eines nichtidealisierten ethischen Autonomiekonzeptes. Als solches ist es an der aktualen bzw. faktischen Fähigkeit einer Person ausgerichtet, rekurrierend auf die spezifische Determiniertheit autonomer Entscheidungen und Handlungen sowie auf ein relativiertes Konzept menschlicher Vernunft. (shrink)

ZusammenfassungOnora O’Neill hat 1984 den Zusammenhang zwischen grundsätzlichen Bedenken gegenüber dem ethischen Autonomiebegriff und der Kritik an der paternalistisch geprägten medizinethischen Praxis hergestellt, nicht die tatsächliche Einwilligung des konkreten Patienten zu berücksichtigen, sondern die angenommene, hypothetische Einwilligung, die ein idealisierter, völlig rationaler Patient geben würde. Im Anschluss an experimentalpsychologische Studien zur subliminalen Wahrnehmung, zu Volition und Handlungskontrolle erfahren kompatibilistische Theorien menschlicher Freiheit innerhalb der theoretischen Philosophie neue Popularität. Eine Handlung ist demnach frei, wenn sie das Resultat bestimmter Fähigkeiten einer Person (...) ist. Der Artikel setzt sich mit zwei dieser Theorien, Henrik Walters Konzept „natürlicher Freiheit“ und Michael Pauens „Minimalkonzeption personaler Freiheit“ näher auseinander—und zwar vorderhand im Hinblick auf den Entwurf eines nichtidealisierten ethischen Autonomiekonzeptes. Als solches ist es an der aktualen bzw. faktischen Fähigkeit einer Person ausgerichtet, rekurrierend auf die spezifische Determiniertheit autonomer Entscheidungen und Handlungen sowie auf ein relativiertes Konzept menschlicher Vernunft. (shrink)

The conception of the doctor–patient relationship under Australian law has followed British common law tradition whereby the relationship is founded in a contractual exchange. By contrast, this article presents a rationale and framework for an alternative model—a “Trust Model”—for implementation into law to more accurately reflect the contemporary therapeutic dynamic. The framework has four elements: an assumption that professional conflicts with patient safety, motivated by financial or personal interests, should be avoided; an onus on doctors to disclose these conflicts; a (...) proposed mechanism to contend with instances where doctors choose not to disclose; and sanctions for non-compliance with the regime. (shrink)

Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities.