PHI 227 Biomedical Ethics

Two major issues

1. Meaning of "competent."
2. Conflict between patient autonomy and the principles of Beneficence and nonmaleficence



Competence/decisional capacity

1. Competent: a legal concept
2. Decisional capacity:
   1. Not always easy to judge, slippery concept
   2. According to the President's Commission, "[it is not] a medical or psychiatric category; it rests on ajudgment of the type that an informed lay person might make -- that the patient lacks the ability to understand a situation and to make a choice in light of that understanding."



Criteria of decisional capacity

1. The awareness that one has a choice
2. A clear understanding of the treatment or procedure
3. The ability to weigh the risks and the benefits of the treatment
4. The ability to make a decision based on the deliberation concerning the pros and cons of the procedure
5. The ability to conceive values
6. The ability to apply one's values to the situation at hand
7. The ability to communicate one's decisions



The Sliding scale strategy

1. Meaning
   Some doctors and ethicists argue that the standard of decisional capacity ought to be adjusted according to the potential harm or benefit that is involved. As the risks of the proposed treatment increase or the benefits decrease more capacity is required for the patient to be considered competent to consent to a treatment. Inversely, as the benefits increase and the risks decrease, more capacity is required for the patient to be considered competent to refuse treatment.
2. Examples:
   1. If the treatment will result in a slight benefit and its refusal only a slight harm, a doctor may accept a very low level of decisional capacity.
   2. If the patient refuses a treatment that will return to a state of health without any significant risk, then a doctor may require a high level of decisional capacity.
   3. It the patient is terminally ill and accepting treatment, would merely prolong the dying process. The doctor may require a low level of competence if the patient refuses the treatment.
3. Problems with sliding scale strategy
   1. Health care providers may manipulate it to declare patients who consent to a treatment competent and those who refuse treatment incompetent.
   2. See questions about readings



Controversial cases

1. Jehovah's Witness who refuses a live-saving blood transfusion and Christian Scientists who refuse treatment
2. Refusal of a treatment which would cure an ailment but would restore a patient to painful condition Example: a severe arthritis sufferer who refuses treatment for her pneumonia. Raises questions of autonomy and quality of life.



Exceptions:

1. Treatment of self-inflicted injuries resulting from an attempt at suicide.
2. Failure to treat will endanger public health as in the case of contagious diseases. Jacobson v. Massachusetts (1905).
3. Treatment necessary to protect an unborn child. Rejected by the Supreme Court.
4. Failure to treat could require a physician to follow a course of treatment that amounts to malpractice United States v. George (1965).



Questions on the readings

The Dax case
1. What is the fundamental issue this case raises according to Englehardt?
2. Why does he think that treating Dax when first admitted to the hospital justified?
3. What alternatives are morally open in this case according to Englehardt? Which does he prefer? Why?
4. What does he think is the greatest tragedy in cases such as Dax's?