Week 3: Autonomy, Consent, Ethical Complexity

advanced directive

• Health decisions, has capacity to make decisions

• If not have one, healthcare do everything they can to save you

• Apply to mental health

  • Ppl who have schizophrenia for example (becomes complex) 

  • Included in MAID (making an informed decision)

CNO pt autonomy and self determination

• Support client in making informed decisions and their healthcare

• Advocates for clients or their representatives, especially when unable to advocate for themselves

autonomy

• Right to freely choose or self-govern

• Highly respected principle, especially in North American society and health care

• Often clashes with other principles 

  • Pt right to choose (autonomy) vs what healthcare care professionals recommend (beneficence, nonmaleficence) 

• Included in most ethics codes 

5 basic elements of autonomy 

1. Be respected

2. Be able to set goals

3. Be able to formulate a plan of action in order to meet goals

4. Be able to reflect of values and beliefs

5. Have the freedom to act on choices

Extent to which someone is able to act/choose autonomously

• Liberty or freedom to decide and act unimpeded or uncoerced by others

• Being adequately informed relative to the decision to be made

• Having rational capacity to understand and deliberate effectively toward decision

Limitation of autonomy

• When a pt is at risk of self-harming or harming others

• When health providers disagree with the pt treatment choice and impose their own views for what they believe is the pt own good

3 acts of autonomy

1. It is intentional, meaning it is self-directed

2. It is done with understanding, implying that there is a role for information

3. It is done without coercion (someone persuading you)

autonomy in healthcare

• Duty of clinicians to respect and enhance pt choice in treatment decisions and healthcare goals 

• Pt education is paramount in supporting their autonomy

How nurses best support clients autonomy

• Advocate for the client

• Educate and inform the client of options of treatments in an accessible/clear way 

• COMPLETING INFORMED CONSENT with the client so the client can decide if to do treatment or not (opt-out)

informed consent

• Person must give it voluntarily

• Be adequately informed

• Have CAPACITY to consent 

• Fundamental idea is that the decision about whether or not to be administered a treatment or engage in care plan belongs by the right to the pt

  • Provider responsible for seeking the pt consent and respecting the pt’s decision to accept/refuse treatment or a plan of care 

• Without pt voluntary consent is to violate that right and could constitute assault/battery (even if provider has acted with best intentions)

Case study: prenatal care and HIV screening

• HIV epidemic

• Anti-retroviral medicines can prevent perinatal transmission of HIV

1. Mandatory testing = provider approaches all women

• Not proving access to only “high risk” women = human-rights based approves to minimize discrimination and drive ppl away from testing/treatment

2. Voluntary counseling and testing (VCT)

• Client initiates HIV testing 

• Accompanied by

  • Pretest counselling

  • Signed documentation of informed consent

  • Post-test counseling 

• Goal to combat discrimination and encourage ppl to come forward for test/treatment 

• Is VCT ethical?

  • Focus on client initiating = women have to ask/seek

  • Women afraid to ask questions, HIV stigma

  • Voluntary counselling did not work as more women affected by HIV because providers believed they could predict which women were at most risk

3. Provider-initiated testing (PITC) (out-out testing)

• Advocated for by the centers for disease control (CDC) and World health organization (WHO) 

• Benefits = increase testing rate

• Opt-out testing mean pt in certain settings/populations are told by providers (provider initiated)

  • They will be tested for HIV endless they explicitly opt out (“I do not want to participate”) 

• Does not require pre-test counselling and specific consent for HIV test 

• Elements of informed consent

  • Provide oral/written information about HIV

  • risks/benefits of testing

  • Implication of HIV test results

  • How test results will be communicated

  • Opportunity to ask questions

Ethical issues that arise - HIV

• Informed consent = not all risk/benefits provided

• Discrimination = do not want to participate

• Paternalism vs autonomy = respect for mother autonomy

• Beneficence = protect infant, society, mother 

• Addressing power differences = empowering women 

• Women more likely to corporate with testing if properly counselled (written informed consent protect women = opt in = providers gives info, examples, side effects, benefits then women decided to op in)