1 Autonomy vs.

Paternalism A contest Between Virtues

VALUE PREFERENCE AS THE BASIS OF HEALTH CARE DECISIONS This example shows that health care decisions are matters not only of medical expertise, but also of individual value preferences. Value Preferences refers to what kind of value the patient gets.

From paternalism to Patient Autonomy This refers to the health care provider and the patients issues. It is because you have to follow your obligation as a health care professional without contradicting the patients autonomy. In the past times, when practitioners had less to offer by way of scientific evidence for their cures and nostrums, society allowed them a greater role in medical decision making. Now, when every treatment is subjected to scientific method and scrutiny, the patient is demanding and receiving a greater role in the decision making process. This processes can be seen from two excerpts one from the Code of Ethics of the American Medical Association and the other from the American Hospital Associations A Patients Bill of rights.

1848 code, section 6 The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions. Patients Bill of Rights The patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of his action.

Paternalism consist of acting in a way that is believed to protect and advance the interests of another even though the actions may be against the desires, or may in fact the freedom of action, of the individual. AUTONOMY VS. BENEFICENCE According to the essay of John Stuart Mill, power can be rightfully exercised over any other member of a civilized community against his will is to prevent harm to others. Autonomy based on medical terms, it refers to the right of an individual for his/her health. Beneficence based on medical terms, it means doing good for an individual that would benefit him/her.

2 The issue for this topic is that which of the basic ethical principles holds supremacy in a given situation.

Standards of Disclosure-- Two standards have been proposed Professional Community Standard It is where the health care provider is bound to provide the amount of information. This is based on the concept that the practitioner and the patient were bound in a special fiduciary relationship.

Reasonable Patient Standard This standard was articulated in the 1972 Canterbury V. Spence case, in which the court ruled that: true consent to what happens to ones self is the informed exercise of a choice, and that entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each. The rationale for this standard is that the type and amount of information needed must be at the patients level if he is truly to be autonomous as a decision maker. One criticism of Reasonable Patient Standard is: The nature of the hypothetical person to ask Who is to say this person is anything like the patient in regard to beliefs, cognitive abilities and social background?

Patient-Centered Standard This more subjective standard would allow a greater differentiation based on patent reference. A patient who values a pain-free life is different from one who values a life with other considerations. Relives in the unique nature and abilities of the individual patient to determine the amount of disclosure needed to satisfy the requirements of informed consent.

Autonomy Reconsidered Autonomy has been considered more important than paternalism

Paternalism - in the context of healthcare is constituted by any action, decision, rule, or policy made by a physician or other care-giver that dictates what is best for the patient without considering the patients own beliefs and value system and does not respect patient autonomy..

3 CONCLUSION Health care provision is a shared practice. The expert and the patient must both work to be sure that what is delivered is satisfactory to each.

There should be a general agreement through the practice of autonomy. 1. The patient has the right to decide the nature of care. 2. The practitioner should make sure that the decision is based on appropriate information. 3. There should be informed consent! 4. The physician must disclose pertinent details about the nature of the treatment, its risks and benefits and any alternatives. This desire to do good is not a justification for overcoming a competent patients personal autonomy. INFORMED CONSENT DERIVED FROM THE TENSION BETWEEN PARTERNALISM AND THE DESIRE FOR PATIENT AUTONOMY ELEMENTS OF INFORMED CONSENT 1.Disclousure: The nature of the condition, various options, potential risk, the professionals recommendation, and the nature of consent as an act of authorization. 2.Understanding: In united states, most states require that the physician provide information at a level that a hypothetical reasonable patient would understand. 3. voluntariness: No efforts toward coercion, manipulation, or constraint are allowed. The patient must be in a position to practice self- determination. 4. Competence: Decision in regard to competence usually take into account experience, maturity, responsibility, and independent of judgment. 5. Consent: An autonomous authorization of the medical intervention

It is important to understand that informed consent does not require full understanding or full voluntariness to be in place. If these criteria were truly to be required, autonomous action would be a rare event. The courts have held that a patient suing under the principle of informed consent must prove the physician failed to inform them of a material risk. Unfortunately, there is no bright line that separates material from immaterial risk. In general, a risk is material if it would be likely to affect a patients decision.

4 Consent may take many forms: ORAL IMPLIED WRITTEN GENERAL SPECIAL CONSENT Informed Demand for Futile Treatment Futility The quality of having no useful result; uselessness. Lack of importance or purpose; frivolousness. lack of effectiveness or success

Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient's medical condition. Medical futility remains ethically controversial for several reasons. Some physicians summarily claim a treatment is futile without knowing the relevant outcome data.

Medical futility" refers to interventions that are unlikely to produce any significant benefit for the patient. Two kinds of medical futility are often distinguished: quantitative futility, where the likelihood that an intervention will benefit the patient is exceedingly poor, and qualitative futility, where the quality of benefit an intervention will produce is exceedingly poor. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile. Futility should be distinguished from such concepts as theoretical impossibility, such expressions as "uncommon" or "rare," and emotional terms like "hopelessness." In judging futility, physicians must distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which appreciably improves the person as a whole. Treatment that fails to provide the latter, whether or not it achieves the former, is "futile."

5 Critical care physicians should support the drafting of state laws embracing futility considerations and should assist hospital policymakers in drafting hospital futility policies that both provide a fair process to settle disputes and embrace an ethic of care.

What are the ethical obligations of physicians when an intervention is clearly futile? The goal of medicine is to help the sick. You have no obligation to offer treatments that do not benefit your patients. Futile interventions are ill advised because they often increase a patient's pain and discomfort in the final days and weeks of life, and because they can expend finite medical resources. Although the ethical requirement to respect patient autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options), it does not entitle patients to receive whatever treatments they ask for. Instead, the obligations of physicians are limited to offering treatments that are consistent with professional standards of care.

Communicating futility The very fact that we use the term MEDICAL FUTILITY in DIFFERENT WAYS WITHOUT CLARIFICATION CAN LEAD TO MISCOMMUNICATION AND MASK VALUE JUDGEMENTS, WHICH MAY BECOME A SUBTLE TO FORM PATERNALISM MEDICAL FUTILITY:

Refers to a medical care that prolongs suffering Does not improve the quality of life Or fails to achieve a good outcome for the patient. however, if e are to make rational judgements regarding futility in a particular case, it would seem that WE NEED TO NARROW THE DEFINITIONS.