Week 6: Advance Directives and Information about Medical Treatment

Guest lectures:

• Oct. 18, Steve Abdool, St. Michael's Hospital, Toronto: "Confidentiality and the Duty to Disclose".
• Nov. 6, Jill Oliver, William Osler Health System, Bramption: "Sex, Conceptual Change, and Ethics: How Changing What We Think Might Change What We Think We Should Do".

Advance Directives

Objective Reasonable Person Rule

A proxy (substitute) decision maker should make a decision in the best interests of an incompetent person using the values that an objective reasonable person would use in the incompetent person's situation.

But the rule does not apply if the incompetent person has left an advance directive, which is a document that stipulates the nature of the health care that the person would like to receive when incompetent.

Malette v. Shulman

Georgette Malette was rendered unconscious by a car accident. Dr. Shulman determined that she needed a blood transfusion to survive. But her purse contained a Jehovah's Witness card forbidding blood transfusions. Shulman gave her one anyway, and was sued when she recovered.

Was Shulman legally liable and/or unethical?

Key issues: patient's right to autonomy vs. doctor's estimate of consequences.

Arguments For Advance Directives

1. ADs extend patient autonomy.
2. ADs promote fair treatment of incompetent patients.
3. ADs reduce anguish in patients' family members who do not have to make decisions for them.
4. ADs reduce psychological distress of health care providers.
5. ADs increase physician-patient communication.

Arguments Against Advance Directives

1. Wishes of competent people may project poorly onto future situations of incompetence
2. Equality does not require same treatment of incompetent persons.
3. People change their minds without updating directives.
4. ADs are biased toward refusal of treatment.
5. ADs may restrict patients' rights, if limited to the terminally ill.
6. ADs may fail to anticipate situations.
7. ADs may undermine informed consent based on patient-doctor communication.

What Form Should an Advance Directive Take?

Medical Directive

Values History

Should all patients be offered ADs?

How often need ADs be updated?

When are patients competent to change their minds?

When should ADs be overruled?

Conclusions

1. ADs are valuable?
2. ADs should permit both refusals and requests for treatment.
3. ADs should be offered to anyone who requests them.
4. ADs should be updated on request.
5. The most recently expressed wishes should be followed.
6. ADs should be enforced by referrals to ethics committees.
7. ADs should be promoted by education.

Information and Medical Treatment

Do Patients Have a Right to their Medical Records?

Yes:

1. Patients have a legitimate interest in information about their health.
2. Doctors have a duty to act with good faith and loyalty.

No:

1. It may not be in the best interests of a patient to know too much.
2. Disclosure may cause unnecessary lawsuits.
3. Medical records may not be understood by the patient.
4. Doctors might keep less thorough notes.
5. Disclosure might hurt the patient or a third party.

Court conclusion: Patients are entitled to reasonable access to their records, but non-disclosure may be warranted if there is a real potential for harm.

Placebos

Placebo = treatment believed to be biologically ineffective but used anyway for psychological or experimental purposes.

Placebo effect = change in a patient's condition due to symbolic value of a treatment rather than its biological effectiveness.

Arguments Against Using Placebos

1. Placebos are deceptive and violate duties to tell the truth.
2. Placebos violate patients' autonomy: right to choose treatment.
3. Placebos can have bad consequences, e.g. when a patient loses trust in a doctors.

Arguments for Using Placebos

1. Placebos work: they make patients feel better,and may be biologically effective because of complex interactions between the brain and the immune system.
2. Placebos are white lies.
3. Placebos are not deceptions, if all the doctor says is that the treatment will make you feel better.

Review Questions for Week 6

1. What is an advance directive?
2. What are five arguments in favor of advance directives?
3. What are five arguments against advance directives?
4. Essay question: Should advance directives be broadly used? Discuss the ethical pros and cons in terms of consequences and rights. For each option, discuss: consequences pro, con, and overall; rights pro, con, and overall; your overall conclusion concerning the options based on consequences and rights.
5. What is a placebo, and what is the placebo effect?
6. What are the main arguments against using placebos?
7. What are the main arguments for using placebos?
8. Essay question: Should doctors use placebos? Discuss the ethical pros and cons in terms of consequences and rights. For each option, discuss: consequences pro, con, and overall; rights pro, con, and overall; your overall conclusion concerning the options based on consequences and rights.

Miscellaneous

Blog post about this course

How to improve your grades

Phil 226

Computational Epistemology Laboratory.

Paul Thagard

This page updated Oct. 29, 2012