Autonomy: Respect for Persons, Decision-making Capacity, & Informed Consent Walter Limehouse MD MUSC Ethics Committee Chair.

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Presentation transcript:

Autonomy: Respect for Persons, Decision-making Capacity, & Informed Consent Walter Limehouse MD MUSC Ethics Committee Chair

objectives Respect for persons Decision-making capacity Informed consent Surrogate decision-making (Williams) Advance directives (Williams)

Respect for persons Belmont Report, 1976 Respect for person – autonomy Beneficence – do good Justice – fair allocation Hippocrates, ancient Greece Non-maleficience – do no harm primum non nocere

Autonomy Hippocratic school paternalistic Modern bioethics Immanuel Kant John Stuart Mill

Respect for person Two ethical conditions Treat individuals as autonomous agents Protect persons with diminished autonomy belmont report

Respect for person Autonomous agent deliberates about personal goals acts as directed by such deliberation belmont report

Respect of person acknowledges right of that person to hold views, make choices, & take action based upon personal beliefs and values requires active efforts supporting others’ capacity for choice reducing constraints upon choice

Autonomy Negative obligation Autonomous action should not be constrained unless harmful to others Positive obligation requires disclosure of information ensures understanding & voluntariness enables decision-making

Autonomy Priority among other principles of bioethics Reduced / absent decision-making Justifies interventions Bekelman & Carrese

Bekelman & Treatment refusals assess decision-making capacity, psychiatric dangerousness, & medical risk address potential reasons/causes choose to respect treatment refusal, to obtain surrogate, or to mandate hospitalization & possibly treatment.

Bekelman & Treatment refusals Homeless schizophrenic person hospitalized with ischemic gangrene refuses L BK & R TransMet amputations

Decision-making capacity & competence competence defines the ability to perform a task vary over time, intermittent requires assessing understanding deliberative capacity & coherence over time

Medical decision-making capacity making a choice understanding relevant details diagnosis, prognosis risk / benefits of treatment alternatives

Medical decision-making capacity appreciating current & future implications of relevant details upon oneself describing how one made choice in context of personal values

Bekelman & Treatment refusals Homeless schizophrenic person hospitalized with ischemic gangrene refuses L BK & R TransMet amputations

Decision-making capacity or legal competence The only freedom which deserves the name, is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs, or impede their efforts to obtain it. John Stuart Mill, On Liberty

Informed consent Threshold elements (preconditions) a. capacity (to understand & decide) b. voluntariness Information elements c. disclosure (material information) d. recommendation (of plan) e. understanding (info & plan) Consent elements f. decision (for / against plan) g. authorization (of plan) (BC, pbe 80)

Informed consent Threshold elements (preconditions) capacity (to understand & decide) voluntariness Beauchamp & Childress

Informed consent Information elements disclosure (material information) recommendation (of plan) understanding (info & plan) Beauchamp & Childress

Informed consent Consent elements decision (for / against plan) authorization (of plan) Beauchamp & Childress

Disclosure standards Professional Reasonable person Subjective Transparency

Surrogate Decision-making Autonomy Substituted judgment Best interests

Advance Directives express autonomous choices previously capable patients in particular clinical circumstances trigger activating advance directive current absence of patient’s decision-making capacity Surrogates apply directives written, oral, or implied prior known patient preferences, values, or relevant actions.

South Carolina Advance Directives Living will Healthcare power of Attorney Aging with Dignity Five Wishes

SC Advance Directives… Physician Orders EMS-DNR POLST paradigm

Summary Respect for persons Decision-making capacity Informed consent Surrogate decision-making Advance directives

Contact Information Walter Limehouse MD MA MUSC – Emergency Medicine 169 Ashley Av, MSC-300, Suite 265 Charleston Sc