1. Medical Decision Making Nuala Kenny SC, OC, MD, FRCP Department of Bioethics (post-rtd) Dalhousie University, Halifax, NS Ethics & Health Policy Advisor Catholic Health Association of Canada Ottawa, Ontario

2.  History  Respect for autonomy  Informed choice Competence Third-party decisions  Models doctor-patient relationship  Shared decision making

3. History of Medical Decision-making  Hippocratic duty of beneficence Beneficence vs paternalism  Doctor as decision-maker  Modern bioethics

5. The Traditional Practice Doctor Decides Patient Welfare Peers/Profession Direct Payment Care by Families

6. Modern Bioethics  Inclusion of many voices & perspectives in increasingly complex, value-laden decisions  Principle-based reasoning Respect for autonomy Beneficence Non-maleficence Justice

7. Elements of Informed Choice: A Tool for Respecting Autonomy  Information Reasonable patient standard Truthfulness vs disclosure  Capacity/competence  Freedom, voluntariness From coercion; from undue fear and from guilt

8. Competence  Capacity to indicate a choice  Understanding relevant information  Making a ‘reasonable’ decision  Using rational reasons to reach a decision

9. Differences re Competence  In Law Here & now decision Presumed Understand the choice & gives reasons  In Medicine Whole person Tested (protected) Understand nature of choice, consequences and alternatives

10. Advance Directive: Continuation of Respect for Autonomy Advance care planning includes a directive A document made by someone while capable concerning health care decisions to be made in the event that the person becomes incapable to make such decisions in the future Instructional directive (‘living will’)-what or how health care decisions are to be made Proxy directive -who is to make health care decisions

11. 3 rd Party Decisions  The patient must be incompetent Fluctuating, deteriorating  Information, capacity, freedom  A decision must be made  The decision must be made as the patient would want using: Substituted judgment Best interest

13. Models of the Doctor-Patient Relationship  The paternalistic model  The informative model  The interpretive model  The deliberative model  Emanuel & Emanuel

14. Issues Determining the Doctor-Patient Relationship  The goals of medicine  Physician’s obligations  Patient values  The understanding of patient autonomy  Emanuel & Emanuel

15. The End of Medicine  The end of medicine is a right and good healing action  E Pelegrino The Philosophical Basis of Medicine

16. Some Deeply Problematic Issues  The doctor’s duty to do no more intentional harm than benefit  Confusion regarding “respect for autonomy” of the patient  Confusion re the goals of medicine  The problem of futility Quantitative vs qualitative  “Best interest” in a consumer world

17. Shared Decisions-The Ideal  The doctor’s role is to provide facts about the disease, prognosis & possible treatments (based on evidence of benefit vs risks/harms)  The patient’s role is to provide the values-conception of the good-to evaluate and then select among the options

18. Difficulties with Division of Roles (Dan Brock)  Doctors’ information as value- neutral  Patients’ values are incorrigible i.e. cannot be mistaken  Assumption that patient values are correct and physician must act on them

19. When Sharing Breaks Down  Unilateral declarations by the doctor  Demands for non-validated and non recommended treatments by patients; litigation  The crucial need for respectful communication  Inevitable distress and compromise of patient welfare

20. The End of Medicine  The end of medicine is a right and good healing action  E Pelegrino The Philosophical Basis of Medicine