Medical Decision Making
Nuala Kenny SC, OC, MD, FRCP
Department of Bioethics (post-rtd)
Dalhousie University, Halifax, NS
Ethics & Health Policy Advisor
Catholic Health Association of Canada
Ottawa, Ontario
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History
Respect for autonomy
Informed choice
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Competence
Third-party decisions
Models doctor-patient relationship
Shared decision making
History of Medical Decision-making
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Hippocratic duty of beneficence
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Beneficence vs paternalism
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Doctor as decision-maker
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Modern bioethics
The Traditional Practice
Patient
Welfare
Direct Payment
Doctor Decides
Care by Families
Peers/Profession
Modern Bioethics
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Inclusion of many voices &
perspectives in increasingly
complex, value-laden decisions
Principle-based reasoning
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Respect for autonomy
Beneficence
Non-maleficence
Justice
Elements of Informed Choice:
A Tool for Respecting Autonomy
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Information
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Reasonable patient standard
Truthfulness vs disclosure
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Capacity/competence
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Freedom, voluntariness
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From coercion; from undue fear and
from guilt
Competence
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Capacity to indicate a choice
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Understanding relevant information
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Making a ‘reasonable’ decision
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Using rational reasons to reach a
decision
Differences re Competence
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In Law
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Here & now decision
Presumed
Understand the choice & gives reasons
In Medicine
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Whole person
Tested (protected)
Understand nature of choice,
consequences and alternatives
Advance Directive:
Continuation of Respect for Autonomy
Advance care planning includes a directive
A document made by someone while
capable concerning health care decisions
to be made in the event that the person
becomes incapable to make such
decisions in the future
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Instructional directive (‘living will’)-what or
how health care decisions are to be made
Proxy directive -who is to make health care
decisions
3rd Party Decisions
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The patient must be incompetent
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Fluctuating, deteriorating
Information, capacity, freedom
A decision must be made
The decision must be made as the
patient would want using:
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Substituted judgment
Best interest
Models of the
Doctor-Patient Relationship
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The paternalistic model
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The informative model
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The interpretive model
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The deliberative model
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Emanuel & Emanuel
Issues Determining the
Doctor-Patient Relationship
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The goals of medicine
Physician’s obligations
Patient values
The understanding of patient
autonomy
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Emanuel & Emanuel
The End of Medicine
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The end of medicine is a right and
good healing action
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E Pelegrino The Philosophical Basis of
Medicine
Some Deeply Problematic Issues
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The doctor’s duty to do no more
intentional harm than benefit
Confusion regarding “respect for
autonomy” of the patient
Confusion re the goals of medicine
The problem of futility
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Quantitative vs qualitative
“Best interest” in a consumer world
Shared Decisions-The Ideal
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The doctor’s role is to provide facts
about the disease, prognosis &
possible treatments (based on
evidence of benefit vs risks/harms)
The patient’s role is to provide the
values-conception of the good-to
evaluate and then select among the
options
Difficulties with Division of Roles
(Dan Brock)
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Doctors’ information as valueneutral
Patients’ values are incorrigible i.e.
cannot be mistaken
Assumption that patient values are
correct and physician must act on
them
When Sharing Breaks Down
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Unilateral declarations by the doctor
Demands for non-validated and non
recommended treatments by
patients; litigation
The crucial need for respectful
communication
Inevitable distress and compromise
of patient welfare
The End of Medicine
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The end of medicine is a right and
good healing action
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E Pelegrino The Philosophical Basis of
Medicine