Key Concepts in Autonomy and Consent

Major Goals in Life

• The essence of individual desire:
  • Major life goal: To do whatever I want.
  • Emphasis on autonomy: Whenever I want is also essential.

Key Themes in Relationships with Healthcare Workers (HCWs) and Patients

1. Autonomy
2. Informed Consent
3. Truthfulness & Honesty
4. Confidentiality

Autonomy According to John Stuart Mill

• J.S. Mill states we should only interfere with a person's freedom in three cases:
  1. The person does not know or understand what is happening.
  2. The person is going to harm themselves.
  3. The person is going to harm another.

Aspects of Autonomy

1. Free Action

   • Can be limited by internal (psychological) and external (social) forces.
   • Not automatic; must demonstrate ability to self-rule.
   • Society defines standards for “poor” or “reasonable” self-rule.

2. Effective Deliberations

   • Good judgment includes being able to rule oneself: reasoning must be logical, sensible, intelligible.
   • Ineffective deliberation may arise from:
     • Misinformation (deception, lies)
     • Missing information
     • Mental/cognitive issues (e.g., delusions, compulsions)

3. Authenticity

   • Being true to oneself, free from both external and internal constraints.

4. Moral Reflection

   • Ability to articulate one's values clearly.
   • Question the choices made—whether they stem from conscious thought or are adopted uncritically.

Respect for Autonomy

• Respecting patient autonomy requires more than merely following consent rules.
• Indicates a commitment to support patient autonomy actively, as highlighted by Janet Storch: “…kept in command of themselves.”

Informed Consent in Healthcare

• Asserts the right to self-determination in medical decisions.
• Conditions for effective informed consent:
  • Patients must be reasonably informed.
  • They must be allowed to make their own decisions.
  • Their decisions must be respected.
• Ethical minimum is a signature on a form; often considered a safeguard against legal issues.

Defining Fully Informed

• There is no standardized definition of what “fully informed” means.
• Some consider fully informed a “fairy tale” in bioethics, reflecting how complex this concept can be.

Health Care Consent Act (HCCA), 1996

• Key elements of consent under HCCA:
  1. Must relate to the treatment.
  2. Must be informed.
  3. Given voluntarily.
  4. Not obtained through misrepresentation.

Consent Checklist Under HCCA

• 1. Nature of treatment
• 2. Expected benefits
• 3. Material risks
• 4. Material side effects
• 5. Alternatives
• 6. Likely consequences

Communication Responsibility of Physicians

• Physicians bear the primary responsibility for ensuring effective communication with patients, which requires significant effort in making sure patients understand treatment options.

Appropriate Information for Informed Consent

• Important components of the information provided to patients:
  a) Reasonable data.
  b) Possible alternatives.
  c) Risks of procedures.
  d) Should be free from coercion.
  e) Patients must be encouraged to make their own decisions.
  f) Focused feedback should be within the physician's expertise.

The Concept of the Noble Lie (Plato)

• A noble lie benefits the deceived individual; distinguishes between moral lying and self-serving deception.

Prevalence and Types of Lies

• Statistics on lying:
  • 20% of community interactions involve lying; students at 33%.
  • Lying is more prevalent in phone interactions than face-to-face.

Types of Lies

1. False Positives: Pretending to like something more than you do.
2. False Negatives: Presenting a lesser opinion of something or someone.

• False positives are reported to be 20-30 times more common than false negatives.

The Shift in Medical Relationships

• From a paternalistic model to a more autonomous patient model.
• The modern approach emphasizes patient well-being and truthfulness in a healthcare context.
• Importance of informing patients: failure to do so might negatively affect their health decisions.

Truthfulness vs. Beneficence

• Patients who are uninformed might neglect necessary medical attention.
• Early diagnosis communication can provide patients with comfort through understanding their situation.
• Protecting patients from the truth may yield safer reactions than anticipated.

Truthfulness vs. Autonomy

• A question arises about exercising self-rule when deception is involved.

Exceptions to Truth-telling

• Supreme Court of Canada recognizes exceptions to truth-telling, especially if it can cause harm to a patient's emotional state.

Positive Outcomes of Truth-telling

• Better treatment adherence.
• Higher patient satisfaction.
• Reduced co-morbidity and need for interventions.

Managing Mistakes in Healthcare

• Apologies can lower the likelihood of litigation.
• Ontario law protects apologies from being considered an admission of liability under the Apology Act 2009.

Confidentiality in Healthcare

• Rooted in the right to privacy and intersects with autonomy.
• Essential for successful healthcare; breaches can hinder patients from accessing necessary services.

Case Study: Mr. T

• A 35-year-old man married for 12 years, fears he has an STI after unprotected sex; finds out about his HIV+ status.
• Ethical dilemma: Should the healthcare provider inform Mr. T's wife, also a patient?