Medical Ethics

Onora O'Neil

• Distinction between ideal theories of consent/autonomy and actual partial consent (basis of her theory).
• Coercion: Doctor does things against the patient's will.
• Deception: Doctor lies or intentionally misinforms the patient.
• Even for an ideal person, coercion and deception make autonomy impossible, extending to actual partial consent/autonomy.
• Coercion and deception are problematic because:
  • You don't know what you're agreeing to.
  • You don't have an accurate representation of what's being done.
  • Coercion deprives you of willing something to happen.

Under O'Neil's Theory:

• Coercion and deception are not entirely ruled out.
• Distinction between fundamental and non-fundamental aspects of a procedure.
• Fundamental aspects: Patient must not be coerced and must be accurately informed.
• Non-fundamental aspects: May contain elements of deception or coercion.

Placebos

• Inert drugs with no chemical/biological effect relevant to disease treatment.
• Work through psychological suggestion.
• O'Neil: Placebos are acceptable if used for non-fundamental aspects of treatment.

Coercion

• Acceptable if it doesn't pertain to fundamental stuff (e.g., restraining a patient for an injection).

Problem with O'Neil's Idea

• The definition of "fundamental" is unclear.
• Candidates for "fundamental":
  • Description of the procedure.
  • Description of the effects of the procedure.
• Difficulty: What is fundamental for a doctor may not be fundamental for a patient (e.g., blood transfusions and religious groups).
• Jehovah's Witnesses and Christian Scientists prohibit blood transfusions.
• There might not be an objective standard for what is fundamental; it depends on one's values.
• Defense of O'Neil: Anything a person might be concerned about should be considered fundamental.
• Challenge: It's hard to create a comprehensive list of concerns.
• Serious question for O'Neil's view: Fundamental according to what standard?

Manipulation and Patient Goals

• Patient's goals should guide medical treatment.
• Cullen and Klein reading: Doctor recommends/sells vitamins to the patient.
• Lipkin: Deception is acceptable if it benefits the patient.
• For O'Neil, patient's goals matter
• Don't manipulate people into doing what you want as a medical practitioner.
• Respecting autonomy means respecting the patient's goals and values.

Summary of O'Neil

• Judgments of autonomy must be contextual.
• Respect for patient autonomy means avoiding deceit, coercion, manipulation, and paternalism.
• Where autonomy is absent, there is no requirement that it be respected
• If a patient has decision-making capability and can be informed, respect their wishes.
• If no autonomy, fall back on beneficence.
• Enhancing patient autonomy is an obligation for doctors.

Lipkin, Cullen, and Klein

Truth in Diagnosis

• 80% of patients want to know if they have a terminal condition.
• Doctors should find out patient preferences (Cullen and Klein).
• Matt Lipkin: It's impossible for a doctor to convey the whole truth; therefore, they are not obligated to do so

Lipkin's Argument: Impossibility of Conveying the Whole Truth

1. Different Understandings:

   • Doctors and patients have different understandings.
   • High stakes and emotions lead to selective hearing.
   • Different conceptions of terms (e.g., "heart condition," "arthritis").
   • Patients are often underinformed and may consult unreliable sources.

2. Patient Preferences and Comprehension:

   • Patients can't comprehend all details.
   • Giving the whole truth can thwart medical aims.
   • Placebos: Power of suggestion is strong and important.
   • Required truth telling removes the tool of placebos.

3. Judging by Intention:

   • Judge what doctors say by their aim, not just truth.
   • The aim is health and patient benefit.
   • Falsity can be justified if it achieves this aim.

Discussion on Placebos:

• Can doctors casually deceive about placebos?
• Would it be okay to treat cancer with a placebo instead of chemotherapy?
• Case-by-case basis for placebos.
• Deception is justified so that way you don't impose fear on a patient

Evaluating Honesty

• Evaluate what doctors say in terms of truth and giving the complete truth is not a good criterion.
• Must look at the further aim of health and patient benefit.
• Medical situations may demand that the naked facts not be revealed.

Cullen and Klein

DBP View (Deceiving a Patient for Their Own Good)

• Permissible if it promotes the health of the patient.
• Cullen and Klein disagree: Deception is wrong.
• Analogy: Deception is the same as taking the life of one person to save others.

Fundamental Principle: Respect for Persons

• Kant, deontology, O'Neil.
• Reasoning ability is the source of our value; it is beyond price.
• Wrong to destroy or interfere with our ability to reason.
• Lying, coercing, substituting goals deprives us of rationality.
• Doctor provides misinformation for the doctor's own good
  Vitamins example

Doctor Misinforming Patients

• Restricts their ability to act freely.
• Devalues/disrespects their ability to reason/make decisions.

Dilemma Doctors Face

• Tell the patient they are terminal and ruin their life, or deceive them for anxiety-free existence?
• Overwhelmingly doctors should inform their patients, with some exceptions.
• Misinformation deprives the patient of the power to plan their lives.

Three Questions for Cullen and Klein's View:

1. What if the patient doesn't want to be told?

   • A desire for ignorance can be an expression of autonomy.
   • Doctors can't assume patients don't want to know
   • Don't deceive, but respect their wish to not know.
     • Override- if terminal conditions can affect other people and or their health

• Best case scenario- is that doctors by absorbing information from patients whether or not they would want to know
  • Go with informing in this case bc people are not rational

1. What if the doctor themselves doesn't know?

• There still might be those cases where the doctor can't tell the patient the truth
• Doctor will claim that the cannot tell them bc it is impossible For example, Lipkin
  • The cant understand it and complete grasp
  • Doctors dumb everything down for patients- the patient needs the understanding to appreciate the nature as seriousness, potential, risk of therapy and available therapies