Informed consent

PRELIMS

Prelims stands for preliminary (points). They are the following:

  1. The principle of not committing any type of harm or evil to the principle of autonomy

  2. Patients have the liberty to choose what should be done to their body or life.

In regard to medical ethics, doctors are not supposed to harm their patience or exacerbate the previous harm done to them when they're in their care. So, nonmalificence appears to be very important in medical ethics because no one is really rejecting this idea but there was a time where informed consent wasn't really important or central.

INFORMED CONSENT

Informed consent happens only if one of the five or all five things exist:

  1. The patient is competent enough to make decisions based on the physician’s examination of the patient: self explanatory

  2. The patient gets optimal disclosure of information; standards for optimal disclosure of information include:

    1. Physician-focused standard - the standards accepted by the community of doctors

    2. Hypothetical patient focused standard - self explanatory

    3. Actual patient-focused standard - when the patient thinks the disclosure of information is adequate

  3. The patient comprehends the information; minimum information must include:

    1. Nature of the procedure

    2. Risks

    3. Alternatives

    4. Expected benefits

  4. The patient voluntarily makes a decision about the treatment

  5. The patient consents to the treatment

Therapeutic privilege: not revealing particular information that will likely cause harm

Waiver: the patient waives their right of informed consent. That might be a small amount of philosophers putting that the waiver is not permissible or allowed but the majority of them believe that the patient waives their rights for this type of consent, then they have the green lights to do things that would be otherwise considered paternalistic.

WHAT MAJOR THEORIES SAY

  1. Kantian ethics: therapeutic privilege is never allowed but the waiver is because of the patient's autonomy

  2. Act utilitarian: this focuses more on the act or whether the choice is going to bring greater or lesser utility

  3. Rule utilitarian: this is the therapeutic privilege that is allowed only when those class of cases bring greater utility. This mainly focuses on the rule

  4. Main action refers to whether or not it matters greatly that patients should be the only arbiter, judge or decision maker of what's good for them

Therefore, autonomy is a value that speaks in favor of paternalism and informed consent. We are also mainly arguing what the relative value of autonomy is or how valuable it is compared to other values.

THE CONCEPT OF INFORMED CONSENT

Types or senses of consent:

  1. SENSE #1 An informed consent that is analyzable as a specific kind of action by patients and subjects: an autonomous authorization (actual consent). NOTE! Shared decision making might improve the value that consent aims to support (which is autonomy)but it's not needed necessarily.

  2. SENSE #2 an informed consent that is analyzable relating to the web of cultural and policy rules and the definition of consent that collectively create the social practice of informed consent in institutional context where subjects and the groups of patients have to be treated the way rules, policies and standard practices require them to be treated; whatever satisfies the rules

THE RELATIONSHIP BETWEEN SENSE ONE AND THE SENSE TWO

Should sense two track the conditions needed for sense one? To prevent ourselves from asking a patient what should be done in every single step in the procedure, sense two is put in place. This method promotes a much more efficient healthcare delivery. As a result, autonomy should be primarily used and extremely important cases for the patient. For example, a procedure or since one is necessary because there's some risk of the patient losing one of their legs, autonomy would have first priority over concerns of efficiency because of this high stake case.

INFORMED CONSENT—MUST IT REMAIN A FAIRYTALE?

Informed consent was less common in the past (20th century) because it was believed that doctors authority was more beneficial for the following reasons:

  1. They applied esoteric knowledge or information that is not easily accessible to the patient

  2. Because of the anxiety, patients are not capable of making decisions that would help them optimally

  3. Doctors have a commitment to altruism or avoiding unselfish regards towards someone’s welfare and this creates a safeguard against abuse

Central reasons to why that authority was questioned later:

  1. Modernized diagnostic tools were introduced

  2. The closed court cases determined the rights of patients to decide their right of autonomy and introduced the idea of joint this is your making between patients and doctors

WHY INFORMED CONSENT WOULD REMAIN AFFILIATED WITH A FAIRY TALE

Because of uncertainties; there is, of course, I'm mostly always a probability (e.g., 98%-60%). We haven't figured out a way to make people live forever… Despite that, acknowledging this type of uncertainty would undermine a doctor's authority and if doctors do acknowledge it's uncertainty, even to themselves, they won't feel the same drive about the profession. This topic poses a problem because of philosophers like John Stewart Mill when he introduced the bridge case: it's okay to be paternalistic if you know for sure the bridge is unsafe and once the patient has been aware of the benefits from the decision, they will most likely accept what's going to be done to them. Therefore, because there is a high uncertainty involved in the medical field, it poses a problem.

THE SOLUTION

Genuine collaboration between patients and physicians cannot be realistic until physicians know:

  1. To not treat their patients like children

  2. How to distinguish the best treatment from the patients preference

  3. How or when to admit to that patience their uncertainties about diagnosis, treatment and prognosis

  4. How to explain to patients the inherited ignorance in the state of the arts and science of medicine

Once patients are aware of the uncertainty, doctors must let patients make value trade-offs. NOTE! Once you do any surgery, the trauma kind of stays with you. So, it appears that this does not explicitly answer the conflict this topic has brought upon us for a while; nothing here guides us to a certain kind of direction of weather the collaboration is paternalistic or collaborative

TRANSPARENCY: INFORMED CONSENT IN PRIMARY CARE

Two standards of informed consent:

  1. Legalistically sends the wrong message (e.g., a doctor providing a patient an exhausted list of all the risks included in the procedure)

  2. Conversationally not workable

He offers the transparency standard: doctors will first explain everything they considered to be important or notable of explaining and then will be there to encourage questions he can answer

TWO STANDARDS

  1. Community standard: what professionals do (allows too much paternalism)

  2. Reasonable standard: what would be acknowledged as reasonable (e.g., a doctor providing a patient an exhausted list of all the risks included in the procedure); not workable

  3. Conversation model (Katz): probably not paternalistic but doesn't submit itself to Legal standards because it is set up intractability or not easily directed as a set of subjective elements

It's still hard to determine if informed consent has been achieved

TRANSPARENCY STANDARD (RESOLUTION)

See THE SOLUTION

Seems like informed consent will remain a fairy tale because of the unequal amount of expertise available…