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Consent to treatment
Published in Gary Chan Kok Yew, Health Law and Medical Ethics in Singapore, 2020
The best interests approach promotes beneficence and welfare for the patient. Moreover, the references to the patient’s past and present wishes, beliefs and values go towards enhancing authenticity in the decisions made. In considering the patient’s past and present wishes, beliefs and values that would influence the decision if he had capacity, the “best interests” approach in the MCA would appear to incorporate, to some extent, the notion of substituted judgement (Chan 2011, at pp. 122–123). Strictly speaking, the “best interests” approach is focused on the welfare of the patient which is conceptually distinct from making a substituted judgement on behalf of the patient (ie, in effect, attempting to make a decision which the patient would have made in the circumstances that may or may not be to promote his best interests). Nonetheless, in considering what the patient would have preferred or desired in the circumstances, the “best interest” approach seeks to promote patient autonomy where possible even in a situation where the patient was mentally incompetent to make the decision.
End-of-Life Issues
Published in Stephen M. Cohn, Peter Rhee, 50 Landmark Papers, 2019
Cooper's article “Pitfalls in Communication” illustrates the many factors that contribute to communication breakdown and include surgeon, patient, surrogate, and systemic factors (Cooper et al., 2014). Surgeons face time constraints, inadequate communication training, and a belief that patients do not want to talk about death and dying. Surgeons are often at a loss because of the uncertainty of the prognosis. They generally tend to overestimate the prognosis and focus on a curative approach. Because of a lack of training in talking about death or in providing a palliative approach to care, surgeons are less likely to respond to the patient's emotional cues. Instead, as a defense, surgeons focus on medical details, offer reassurance or problem solving and avoidance. There are multiple patient variables that come into play at the end of life. Race, religiosity, functional ability, and availability of family support all affect the intensity of treatment at the end of life. Surrogate decision makers are often unprepared to use substituted judgement. They must make decisions based on what the patient would want, or when unclear, decide what is in the patient's best interests.
Working Out What Will Benefit Patients
Published in Tom Walker, Ethics and Chronic Illness, 2019
There is however a second problem with my initial formulation of premise two, one that is potentially more significant. That argument made two empirical claims. First, that where the patient is a competent adult she is a better judge of what is best for her than anyone else (including the healthcare professionals treating her). Second, that where the patient is not a competent adult, her carers are better judges of what is best for her than anyone else (including both healthcare professionals and the patient herself). Because whether or not a patient is competent changes over time, this implies that who is the best judge of a patient’s best interests also changes over time. For example, it implies that as an adult’s competence declines due to the onset of dementia there comes a point at which she is no longer the best judge of her own interests; and that as a child grows up there comes a point at which she becomes the best judge of her own interests.12 These changes do not happen overnight. Instead they take place over an extended period of time. During that transitional period it will sometimes be unclear who is the best judge of what is best for the patient. This creates a problem for the argument we are investigating. It says that healthcare professionals should use the most reliable method to work out what is prospectively best for their patients, but during this period it is unclear what method is most reliable.
Tube Feed or Not Tube Feed: Ethics beyond the Consult Question
Published in The American Journal of Bioethics, 2023
Joan Henriksen, Nina Current, Scott Nelson
While it is central to the ethics role to argue for the strongest defensible reasoning in answering ethical questions, that isn’t the extent of the help we can offer (American Society of Bioethics and Humanities’ Core Competencies Update Task Force 2011). With training and experience, ethicists can foster positive relationships and create spaces that preserve complexity and nurture dialogue without having to reduce the problem or the people (Austin 2017). We have found that a critical first step for the ethicist is to affirm the experience of the patient, family, and clinical team. Validate that the situation is challenging in its moral dimensions and there is no easy answer. Attributing good intentions to everyone can soften potential defensiveness and permit people to attend to the deeper questions at play. These cases seem to bring out heightened emotion in people and may tempt them to clutch at the “rightness” of their own view while vilifying other views. But the issues of what constitutes the patient’s best interests and who gets to decide that are what require debate here.
The Consequences of Access to Unproven Treatments: Medical Ethics Didn’t Create the Problem, and It Isn’t the Solution
Published in The American Journal of Bioethics, 2021
Indeed, using revisions to the codes of ethics to implement either of these changes—eliminating the need for consent in some circumstances, or restricting patient access to certain unproven treatments—would be particularly unfortunate, given the times we are living in. Every day we see new evidence that the poor, the disenfranchized, and the vulnerable are suffering disproportionately from the effects of Covid-19. Implementing vague ethical rules that weaken the ability of doctors to act in the best interests of their patients poses a real risk of further exacerbating this disparity: the patients who are more powerful, better informed, and savvy will likely be best able to find doctors who have the desired interpretation of those vague rules and who provide the treatments they want. And sadly, as we have seen time and again, the vulnerable will be the ones losing out (Menikoff with Richards 2006, 140–141).
Cognitive Transformation, Dementia, and the Moral Weight of Advance Directives
Published in The American Journal of Bioethics, 2020
In standard medical decision-making, patients are free to make their own choices regarding their treatment, so long as the patient in question is judged by medical professionals to have the requisite mental capacity to make an informed decision (Groll 2015).1 When capacity is compromised by a condition such as late-stage dementia, the patient is judged to no longer have the ability to know what is in their best interests.2 In such cases, the responsibility for the decision of how to act in the patient’s best interests is left in the hands of medical professionals or family members. Making this decision is particularly problematic, even harrowing, in cases in which the patient’s current preferences contradict their preferences as expressed in an advance directive. Advance directives are documents that allow individuals to set out directions and preferences for their future medical care, in the eventuality that they lose their decisional capacity (de Boer et al. 2010, 202).3 These documents have traditionally been conceived of as an effective means of extending an individual’s autonomy from their current self, as an individual who has decisional capacity, onto their future self, who lacks it.