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Presentation at a training program ‘Applying the
Principles of Ethics to Clinical Practice:’ held at Aramco Dhahran April 6,
2015 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH
(Harvard) Chairman of the Ethics Committee King Fahad Medical City.
The Patient's
Autonomous Right to Consent
·
No medical procedures can be carried out without informed consent of
the patient except in cases of legal incompetence.
·
The patient has the purest intentions in decisions in the best
interests of his or her life. Others may have bias in their decision-making.
·
The patient is free to make decisions regarding the choice of
physicians and treatments.
The Patient's
Autonomous Right to Consent - 2
·
Consent can be by proxy in the form of the patient delegating decision
making to a proxy or can be prospective by means of a living will.
·
Spouses and family members do not have an automatic right to consent
for a competent patient. A spouse cannot overrule the patient’s choice.
Conditions of
Informed Consent
·
Disclosure by the physician
·
Understanding by the patient
·
Voluntariness of the decision
·
Legal competence of the patient
·
Explanation of all alternatives
Conditions of
Informed Consent - 2
·
Recommendation of the physician on the best course of action
·
Decision by the patient
·
Authorization by the patient to carry out the procedures.
·
Consent is limited to what was explained to the patient except in an
emergency.
Refusal of
Consent
·
Refusal to consent must be an informed refusal (patient understands
what he is doing).
·
Refusal to consent by a competent adult even if irrational is
conclusive and treatment can only be given by permission of the court.
·
Doubts about consent are resolved in favor of preserving life.
Proxy Consent
·
Decision by a proxy can work in two ways: (a) decide what the patient
would have decided if able (b) decide in the best interests of the patient.
·
The living will has the following advantages: (a) reassuring the
patient that terminal care will be carried out as he or she desires (b) providing
guidance and legal protection and thus relieving the physicians of the burden
of decision making and legal liabilities (c) relieving the family of the mental
stress involved in making decisions about terminal care.
Proxy Consent - 2
·
The disadvantage of a living will is that it may not anticipate all
developments of the future thus limiting the options available to the
physicians and the family.
·
The device of the power of attorney can be used instead of the living
will or advance directive.
·
A do not resuscitate order (DNR) by a physician could create legal
complications that have not been discussed thoroughly.
Consent for
Children
·
Competent children can consent to treatment but cannot refuse
treatment.
·
The consent of one parent is sufficient if the other one disagrees and
the treatment is life saving
·
Parental choice takes precedence over the child’s choice.
·
The courts can overrule parents.
·
Life-saving treatment of minors is given even if parents refuse.
·
Parental choice is final in therapeutic or non-therapeutic research on
children.
Mental Patients
·
Mental patients cannot consent to treatment, research, or sterilization
because of their intellectual incompetence.
·
Mental patients are admitted, detained, and treated voluntarily or
involuntarily for their own benefit, in emergencies, for purposes of
assessment, if they are a danger to themselves, or on a court order.
·
Suicidal patients tend to refuse treatment because they want to die.
Consent for the
Unconscious
·
For patients in coma, proxy consent by family members can be resorted
to.
·
If no family members are available, the physician does what he as a
professional thinks is in the best interest of the patient.
Discussion Case
#1:
A patient was
brought to the emergency room by the police after attempting to kill himself by
hanging. He was unconscious when first brought in and had a signed suicide note
in his shirt pocket saying that he wanted to die. The doctors ignored the note
and started resuscitation measures. The patient became conscious after 30
minutes and protested at the medical treatment arguing that he wanted to die.
The doctor was thinking of stopping resuscitation measures when the patient’s
father and wife arrived and instructed the doctor to continue resuscitation.
Discussion Case
#2:
A 40-year old
policeman refused surgery to drain a pyomyositis abscess. He still refused
surgery after the abscess burst spontaneously. The surgeons sedated him and
carried out the surgery without his consent.
Discussion Case
#3:
A 42-year old
actress pregnant for the first time refused an elective caesarean section
because an abdominal scar would ruin her career. She continued to refuse the
procedure when labor became obstructed and signs of fetal distress appeared.
The obstetrician went ahead to operate on the basis of consent by the husband.
The baby was delivered alive and well.
Discussion Case #4:
A conscious and
competent patient told nurses on admission to the ICU that he did not want his
family to be told anything about his condition. When his condition deteriorated
the physicians wanted to consult his family about end of life decisions but he
refused to give up his right to confidentiality.