PHIL 2390H Chapter Notes - Chapter 2: Jay Katz, Reasonable Person, Twin
26 Jun 2018
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Chapter 2 Medical Decision-Making: Patient Self-Determination and
Deciding for Others
2.1 Introduction
- Respect for autonomy: the rational, mentally mature individual’s right to make decisions
regarding his or her own life which obligates HCPs to allow these patients to direct their
own medical care.
- Since autonomy doesn’t consider constraints (i.e. fear, pain, depression, denial) which
may potentially encumber patient or surrogate decision-making, some ethicists find the
term inadequate.
-Competence: An individual’s ability to perform a task; competence to make medical
decisions requires the rational, mentally mature decision-maker to (1) be free from any
internal or external constraints that might impede his ability to understand the medical
situation, prognosis, and treatment options and the risks of treatment and non-treatment,
and (2) be able to make a decision that reflects his long-term, settled values.
-Substituted judgement: a decision made by a surrogate decision-maker or HCP for a non-
competent patient, based on what the patient would want if he were able to decide for
himself.
-Proxy directive: a legal document in which the competent patient designates a person to
make medical decisions for her when she is no longer competent to speak for herself.
-Instructional advance directives: written statements made while the patient is competent
for use at a time when she is no longer competent, stating what medical treatment would
(not) be acceptable to her.
-Informed consent: voluntary consent to a treatment made by a competent patient or
surrogate/representative who is adequately informed of all relevant information
pertaining to the treatment and its alternatives.
-Prima facie right: a moral right that must be honoured unless it comes into conflict with
the moral right of another; a prima facie right is limited, not absolute.
-Ethical relativism: the claim that there are no universal moral obligations binding on all
people in all places at all times always, that morality is created by individuals or by
cultures/societies so each is morally right and none is morally wrong.
2.2 The Concept of Informed Consent
Ruth R. Faden and Tom L. Beauchamp p.44-47
-Informed Consent: voluntary consent to a treatment made by a competent patient or
surrogate/representative who is adequately informed of all relevant information
pertaining to the treatment and its alternatives. p.24
-Sense 1: informed consent is analyzable as a kind of action by individual patients and
subjects –an autonomous authorization.
-Sense 2: informed consent is analyzable in terms of the web of cultural and policy rules
and requirements of consent that collectively form the social practice of informed consent
in institutional contexts where groups of patients and subjects must be treated in
accordance with rules, policies, and standard practices.
oInformed consents are not always autonomous acts, nor are they always in any
meaningful respect authorizations.
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2
SENSE 1: INFORMED CONSENT AS AUTONOMOUS AUTHORIZATION
- An informed consent an autonomous action by a subject or a patient that authorizes a
professional either to involve the subject in research or to initiate a medical plan for the
patient (or both).
- Informed consent in sense 1 is given if a patient or subject with
1. Substantial understanding
2. In substantial absence of control by others
3. Intentionally
4. Authorizes a professional (to do intervention I)
- A person whose act satisfies 1-3 but who refuses an intervention gives an informed
refusal.
- The problem of shared decision-making:
oJay Katz and the President’s Commission have tended to equate the idea of
informed consent with a model of “shared decision-making” between doctor and
patient.
oKatz’s work “the idea of informed consent” and “mutual decision making” are
treated as virtually synonymous terms.
oWe endorse Katz’s view that effective communication between professional and
patient or subject is often instrumental in obtaining informed consents (sense1),
but we resist his conviction that the idea of informed consent entails that the
patient and physician “share decision-making” or “reason together”, or reach a
consensus about what is in the patient’s best interest.
oIt is the essence of informed consent in sense 1 only that the patient or subject
authorizes autonomously; it is a matter of indifference where or how the proposal
being authorized originates.
oi.e. One might advocate a model of shared decision-making for the doctor-patient
relationship without simultaneously advocating that every medical procedure
requires the consent of patients. (some decisions are likely always to remain
subject exclusively to the physician’s authorization).
- Authorization:
oIn authorizing, one both assumes responsibility for what one has authorized and
transfers to another one’s authority to implement it.
oThere is no informed consent unless one understands these features of the act and
intends to perform that act.
oOne must understand that one is assuming responsibility and warranting another
to proceed.
oThe person who authorizes uses whatever right, power, or control he or she
possesses in the situation to endow another with the right to act***
In doing so, the authorizer assumes some responsibility for the actions
taken by the other person.
SENSE 2: INFORMED CONSENT AS EFFECTIVE CONSENT
- Policy-oriented sense whose conditions are not derivable solely from analyses of
autonomy and authorization, or even from broad notions of respect for autonomy.
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Document Summary
Respect for autonomy: the rational, mentally mature individual"s right to make decisions regarding his or her own life which obligates hcps to allow these patients to direct their own medical care. Since autonomy doesn"t consider constraints (i. e. fear, pain, depression, denial) which may potentially encumber patient or surrogate decision-making, some ethicists find the term inadequate. Substituted judgement: a decision made by a surrogate decision-maker or hcp for a non- competent patient, based on what the patient would want if he were able to decide for himself. Proxy directive: a legal document in which the competent patient designates a person to make medical decisions for her when she is no longer competent to speak for herself. Instructional advance directives: written statements made while the patient is competent for use at a time when she is no longer competent, stating what medical treatment would (not) be acceptable to her.
