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Who Decides in Health Care?

Who Decides in Health Care?. Ethics Champions April 9, 2008 Carol Bayley, PhD CHW VP Ethics and Justice Education. Overview. How self-determination replaced “do no harm” as the first principle in medical ethics Elements of informed consent Threshold is capacity

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Who Decides in Health Care?

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  1. Who Decides in Health Care? Ethics Champions April 9, 2008 Carol Bayley, PhD CHW VP Ethics and Justice Education

  2. Overview • How self-determination replaced “do no harm” as the first principle in medical ethics • Elements of informed consent • Threshold is capacity • Disclosure, understanding, authorization • Alternatives • Substituted judgment • Best Interest • When informed consent is necessary; the emergency exception

  3. The Case of Jeanne P. 75 Year old white urban widow; 3 adult children Stage 4 lung cancer (lung removed; chemo) Stable for five years Chemo “stopped working”; tumors grew Tumors produce clotting factor. “Blood thinners” produce stroke.

  4. Galloping (and incomplete) History of Medical Ethics • 2000 years : do no harm • World War II; Nazi experiments • Nuremburg trials, Nuremburg code • “Do No Harm” does not work • Tuskegee, Willowbrook, series of cases in development of legal doctrine of informed consent • The Belmont Report

  5. The Belmont Report • Respect for Persons • Beneficence (flip side: non-maleficence) • Justice

  6. Respect for Persons • Respect autonomy • The patient (or research subject) accepts or refuses treatment (or participation in research) • Vulnerable patients (or subjects) are owed special protection

  7. The (capacitated) patient accepts or refuses treatment. • What is capacity? • What is informed consent?

  8. Informed Consent • Information (clinician->patient) • Consent (patient->clinician)

  9. Information • Disclosure • Understanding • Alternatives

  10. Consent • Voluntary • Uncoerced • Authorization

  11. What is the next best thing? • Substituted judgment • Best interest

  12. When is informed consent NOT necessary? • Almost never! • The emergency exception • Informed consent is necessary even when: • Patient is unreasonable, angry, tired, scared, sick • Patient seems to be making the “wrong” choice • Doctor really knows best • It’s really inconvenient

  13. Back to Jeanne P. • Children know her well, she trusts them. • Jeanne understands she will die at some point but doesn’t want to talk about it. • What is the goal of informed consent?

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