Autonomy, Paternalism, Consent

Question 1

What is autonomy

Answer 1

Deciding the direction in which one’s life should go

Promotes our best interests
We all have different values, priorities, aspirations, making us best placed to know what is in our own best interests

Question 2

How could you navigate ‘bad’ medical decisions

Answer 2

There is more to wellbeing than medical wellbeing

Medical best interests are not the same as best interests overall

Question 3

Why is choice and free will important

Answer 3

Being able to make meaningful choices is fundamental to being human

Without free will, we do not have moral responsibility

Making decisions, regardless of whether they are bad or good is important to flourishing as an individual

Question 4

How would we respect autonomy in society

Answer 4

Society must enable individuals to develop and reflect on their values and must ensure that individuals feel confident to express their values and confident that their wishes will be respected

Autonomy must be respected for trivial and major choices

Question 5

What do you need to make autonomous choices

-how can HCPs support patients make autonomous choices

Answer 5

Understand information

• provide adequate information
• clear explanations
• time to consider options
• no external pressures
• providing reasonable choices

Form values
-being non judgemental to the individual making the decision

Make decisions based on values and understanding of information

Question 6

What is the value of enabling autonomy

Answer 6

Help doctors give better advice
Enable better decision making
Improve mutual understanding
Improve trust
Improve adherence

Question 7

What kind of decision making do our patients want

Answer 7

Some want to doctor to make treatment decisions for them because they trust their doctors
-they still want to understand what is being proposed and why

Patients cite

• clear explanations
• truthfulness
• good communication as essential for building trust => patients feed confident that they have control over what is done to them

Question 8

What are the limits to autonomy

Answer 8

If a decision puts others at harm

Question 9

What is paternalism

-what form could this take

Answer 9

Overriding or undermining a patient’s autonomy based on the healthcare professional’s view of the patient’s best interests

Presenting only 1 side of the argument
Withholding information
Coercion
Lying

Question 10

Withholding information

-is this morally the same as lying

Answer 10

No

• withholding information restricts autonomy less
• patients may actively collude in withholding of information
• impossible to tell patient everything
• less likely to cause mistrust

Yes

• if the intention is the same
• cannot assume that patient’s don’t want to know
• would not differ from lying if you know the patient would be influenced by the information

Question 11

Is paternalism justified in the context of bad news

-how would you promote autonomy as much as possible

Answer 11

Most patients want to know their diagnosis

• many suspect before the doctor confirms it
• knowing the diagnosis and prognosis affects other decisions
• may increase distrust if they suspect the doctor is not being honest with them

The manner in which you break the bad news is important

Question 12

Is paternalism justified in the context of risks and side effects
-how would you promote autonomy as much as possible

Answer 12

Risks and side effects are factual

The significance given to a specific risk or side effect is dependent on the individual’s values

Valuable to understand the patient’s perspective and ensure the patient has the correct information

Question 13

Do doctors know best

Answer 13

Doctors are often best placed to make medical best interests decisions

Medical best interests ≠ overall best interests
-even close family members and friends may be mistaken about each other’s values and priorities

Question 14

How would you manage a situation where there is disagreement between medical best interests and patient autonomy

Answer 14

If we accept the fundamental importance of autonomy, we must respect autonomy equally in all people capable of autonomous decision making

But what are the limits to autonomy?
We must apply these limits consistently

We could take a paternalistic approach if we believe that something else is in their best interests
-fine line between legitimate persuasion and undue pressure
-‘maternalism’ - use of guilt to change someone’s mind
But we can never know what is actually in someone’s best interests

Improved communication between the 2 parties to understand the different perspectives

Question 15

What are the rights and duties of a pregnant patient

Answer 15

A pregnant patient does not lose any of their legal rights by virtue of being pregnant
-has the same legal right as any other competent adult

Question 16

How would you manage a situation where the mother is acting in a way that may harm her unborn child

Answer 16

We live in a society where forcible detention is only permissible for criminals

• should pregnant patients who continue to smoke or drink heavily or take drugs be treated as criminals
• we need to be consistent with how we limit patient autonomy so this would have to apply to current smokers too

The relationship between alcohol, drugs or abuse and adverse fetal outcomes is not straightforward
-argued that it is inappropriate to try to criminalise a pregnant patients actions when much of the fault lies within societal inequalities

Question 17

When are advance decisions valid

Answer 17

When a patient has made it

• when they have capacity
• when you have specified the treatment that you are refusing and situation

Question 18

When would advance decisions not be valid

Answer 18

You cannot ask for treatment
If the treatment being refused is unclear
If you have cancelled you AD since making it
If you have an LPA
If you have become capable of making the decision yourself that you mention in your advance decision, at the time that treatment is offered to you
If there has been a change in circumstances

If they are under the MHA