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Who Decides in Health Care?

Explore the evolution of medical ethics, from the principle of "do no harm" to the importance of self-determination and informed consent. Learn about the elements of informed consent, capacity threshold, disclosure, understanding, authorization, alternatives, substituted judgment, and best interest. Delve into the case of Jeanne P., a 75-year-old widow with lung cancer, to understand the complexities of informed consent. Discover the principles of the Belmont Report, including respect for persons, beneficence, and justice. Understand the significance of capacity and informed consent in healthcare decision-making.

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Who Decides in Health Care?

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  1. Who Decides in Health Care? Ethics Champions April 9, 2008 Carol Bayley, PhD CHW VP Ethics and Justice Education

  2. Overview • How self-determination replaced “do no harm” as the first principle in medical ethics • Elements of informed consent • Threshold is capacity • Disclosure, understanding, authorization • Alternatives • Substituted judgment • Best Interest • When informed consent is necessary; the emergency exception

  3. The Case of Jeanne P. 75 Year old white urban widow; 3 adult children Stage 4 lung cancer (lung removed; chemo) Stable for five years Chemo “stopped working”; tumors grew Tumors produce clotting factor. “Blood thinners” produce stroke.

  4. Galloping (and incomplete) History of Medical Ethics • 2000 years : do no harm • World War II; Nazi experiments • Nuremburg trials, Nuremburg code • “Do No Harm” does not work • Tuskegee, Willowbrook, series of cases in development of legal doctrine of informed consent • The Belmont Report

  5. The Belmont Report • Respect for Persons • Beneficence (flip side: non-maleficence) • Justice

  6. Respect for Persons • Respect autonomy • The patient (or research subject) accepts or refuses treatment (or participation in research) • Vulnerable patients (or subjects) are owed special protection

  7. The (capacitated) patient accepts or refuses treatment. • What is capacity? • What is informed consent?

  8. Informed Consent • Information (clinician->patient) • Consent (patient->clinician)

  9. Information • Disclosure • Understanding • Alternatives

  10. Consent • Voluntary • Uncoerced • Authorization

  11. What is the next best thing? • Substituted judgment • Best interest

  12. When is informed consent NOT necessary? • Almost never! • The emergency exception • Informed consent is necessary even when: • Patient is unreasonable, angry, tired, scared, sick • Patient seems to be making the “wrong” choice • Doctor really knows best • It’s really inconvenient

  13. Back to Jeanne P. • Children know her well, she trusts them. • Jeanne understands she will die at some point but doesn’t want to talk about it. • What is the goal of informed consent?

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