Practical Decision Making in Health Care Ethics: Cases and Concepts

By Raymond J. Devettere | Go to book overview

FOUR

Making Health Care Decisions

DECISION MAKING in clinical settings can be very complicated. Various parties have legitimate interests, and one of the parties, the patient, may be so affected by medical problems that for him or her to make good decisions is unlikely or impossible. In this chapter we focus on the decision making of the patient and the physician. In chapter 5 we will describe what happens when a patient has lost decision-making capacity and a proxy or surrogate, usually from his family, speaks for the patient with the physician.

The first section of this chapter discusses the complexity inherent in making health care decisions. The second section considers the capacity of a patient to make decisions, what constitutes capacity, and how it is determined. The third section explains informed consent, the most distinctive feature of patient decision making in clinical settings. The fourth section covers the advance directives people can put in place to retain some decision-making authority if they should ever lose the capacity to make decisions. The final section discusses the Patient Self-Determination Act and shows, by looking at the research project known as SUPPORT and a case study, how difficult it has been to change the clinical culture in hospitals so that patients and their families can carry out their reasonable wishes at the end of life.


COMPLEXITY OF HEALTH CARE DECISIONS

The complexity arises from three main sources: (1) both the physician and the patient are actively involved in making decisions, and they may disagree about what is proper medical treatment; (2) the patient's ability to make decisions may be undermined by his illness—it is hard to make good decisions about anything when we are sick or limited by external factors; (3) health care decisions often involve important moral issues, and good moral decisions are not always good clinical decisions.


Disagreements between Physician and Patient

As was noted in chapter 3, for a long time it was taken for granted that the physician should make the decisions about treatment. This is known as medical paternalism. When it was operative, there were seldom disagreements between physician and patient because the physician made the decisions unilaterally. More recently some have reacted to this paternalism by proposing the principle of patient autonomy or patient self-determination and by encouraging patients' rights. This movement makes the patient the primary decision maker. It also sets the stage for conflict; physicians cannot abdicate their responsibility for the medical treatment they provide, or can provide, for their patient.

We now recognize that neither medical paternalism nor patient autonomy provides the best in health care decisions. Medical paternalism, however well motivated, disenfranchises the patient. On the other hand, patient autonomy, however well grounded in a person's right to choose what happens to him, disenfranchises the physician.

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Practical Decision Making in Health Care Ethics: Cases and Concepts
Table of contents

Table of contents

  • Title Page iii
  • Contents ix
  • Preface to the Third Edition xiii
  • Introduction xv
  • One - What is Ethics? 1
  • Two - Prudence and Living a Good Life 20
  • Three - The Language of Health Care Ethics 47
  • Four - Making Health Care Decisions 70
  • Five - Deciding for Others 99
  • Six - Determining Life and Death 121
  • Seven - Life-Sustaining Treatments 150
  • Eight - Cardiopulmonary Resuscitation 181
  • Nine - Medical Nutrition and Hydration 202
  • Ten - Reproductive Issues 232
  • Eleven - Prenatal Life 263
  • Twelve - Infants and Children 286
  • Thirteen - Euthanasia and Physician-Assisted Suicide 321
  • Fourteen - Medical Research 357
  • Fifteen - Transplantation 394
  • Sixteen - Medical Genetics 420
  • Seventeen - Social and Political Issues 458
  • Glossary 485
  • Index of Cases 493
  • Index 495
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