Autonomy and Competence and Capacity to make Decisions

1. Autonomy and Competence and Capacity to make Decisions Eshiet I.

2. Autonomy This is a basic fundamental human right. It is the most fundamental principle underlying all health-care ethics. This is the patient’s right to make their own decisions after being properly educated and informed.

3. Beneficience Itis the responsibility of the physician to always act in the best interest of the patient.

4. Paternalism This is the right and duty of parents to override the preferences of the children in favor of their real or true interest. In the context of healthcare is constituted by any action, decision, rule or policy made by a physician or other care- giver, or a government, that dictates what is best for the patient(s) without considering the patient’s own beliefs and value system and doesn’t respect patient’s autonomy.

5. Case 1 A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter's death). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars

6. Competency Competence is a legal term Only a court can determine that a patient is incompetent. All adult patients are deemed competent unless specifically proven otherwise. Physicians can determine whether or not a patient has the capacity to understand his medical condition.

7. The physician determines the capacity of the patient to comprehend his/ her medical problems based on whether there is an organic delirium due to a medical condition such as a sodium problem, hypoxia, drug intoxication, meningitis, encephalitis, or a psychiatric disorder. This is done largely based on a neurological examination testing memory, comprehension, reasoning, and judgment.

8. Conditions for competence • * able to comprehend information • * able to restate information in one's own terms • * able to act from stable set of values • * free from: • acute anxiety • acute depression • denial

9. Competency in minors The neighbour of a 14- year old boy brings him to the emergency department after sustaining a laceration to the scalp from head trauma. You evaluate him and determine that suturing of the scalp will be necessary. Which of the following is the most accurate? • He is an emancipated minor; the patient can give consent • The neighbour can give consent • Wait for the consent of at least one parent • Wait for the consent of both parents • Consent is not necessary in this case

10. Partial Emancipation A 15- year old girl comes to the clinic for dyspareunia and a vaginal discharge. On speculum examination you find she has cervicitis. The pregnancy test is negative. The infection is modest and there is no emergency. What is the appropriate action to take? • Ceftriaxone/ azithromycin now in a single dose • Make at least a “ good faith” effort to notify her parents and treat her • Wait to inform at least one parent • Treat only if the patient agrees to inform her parents • Treat her now and inform the parents later.

11. A 16- year old female comes to the clinic after missing a period. Her pregnancy test is positive and she wants to start prenatal care with you. She is adamant that you keep the pregnancy confidential from her parents. What should you tell her? • “ I will give you the care you need and keep it confidential”. • ” I will not mention it to your parents unless they ask. I can’t lie”. • “ I am sorry, but I must tell them”. • “ I will not tell your parents, but I must inform the father of the baby”.

12. Emancipated Minor A small number of minors, mostly at older ages such as 16 or 17, may be considered ‘emancipated’ or freed from the need to have parental consent for medical care. Criteria: • Married • Self- supporting • Living independently • In the military • Parent of a child they themselves support.

13. Parental Refusal of Life Supporting therapy for Minors A 12 – year old boy and his father are involved in a motor vehicle accident that results in a severe hemorrhage requiring an urgent blood transfusion. Both of them are clearly alert and understand that without the blood they may die. They are both Jehovah’s Witnesses and are refusing blood transfusion on religious grounds. What should you do? • Honor their wishes • Obtain court order to transfuse the child • Give blood to the child and not the father • Psychiatric evaluation • Use intravenous iron in both of them as a blood substitute

14. Psychiatric Patients A 52 – year old man with cerebral palsy is being evaluated for screening colonoscopy. He has a mental age of 8 and a second- grade reading level in terms of comprehension. He survives on public assistance and a part – time job sweeping floors. You fully explain the procedure to him in terms of risks and benefits. He refuses the procedure on the basis of “ I just don’t want it”. What should you do? • Perform the procedure • Seek consent from the family • Honor his decision and do not to the colonoscopy • Seek a court order mandating the procedure