Decision making for patient choice,
autonomy and best interests
Dr Franco Moscuzza
• decision making for patient choice and autonomy
• the clinicians role to inform decision making
• case study: refusal of treatment
Thoughts.....?
• Moral difference between two?
• Utilitarian vs Deontology (Kant) Ethics
• or ' best outcome' vs 'doing the right
thing'
• fMRI differences
Case study
• Proposal presented to CEAG for routine
HIV testing of all adult patients attending
A&E …..without any individual consent
process
Who should make decisions?
• Doctor .....Paternalistic
• Patient .....Autonomy
Origins
• Nuremberg Code 1947
• Declaration of Helsinki 1964
• Belmont Report 1978
• Principles of Biomedical ethics - Beauchamp &
Childress 1979
Tuskegee Study of Untreated
Syphilis in the Negro Male (or the
Tuskegee Experiment)
1932 and 1972 in Tuskegee, Alabama by the U.S.
Public Health Service.
399 poor, mostly illiterate, African American
sharecroppers with syphilis to study for research
related to the natural progression of the disease if left
untreated.
By the end of the study in 1972, 74 of the test subjects were
alive
28 of the original 399 men had died directly of syphilis,
100 were dead of syphilis related complications
40 of their wives had been infected,
19 of their children had been born with congenital syphilis.
Belmont Principles
• Respect for persons
• Beneficence
• Justice
• Applied to: informed consent, riskbenefit assessment and selection of
research subjects
Basic Principles of Bioethics
Beauchamp & Childress 1979
•
•
•
•
respect for autonomy
non-maleficence
beneficence
justice
Who should make decisions?
• Doctor .....Paternalistic
• Patient .....Autonomy
Good Medical Practice
GMC 2008/2013
How has the law changed
• Bolam ..... 1957
• Bolithio
• Sidaway
• Afshar
• Montgomery....2015
Bolam v Friern Hospital Management
Committee
[1957] 1 WLR 582
..... that he is not guilty of negligence if he has acted
in accordance with a practice accepted as proper by
a responsible body of medical men skilled in that
particular art.
Bolitho v. City and Hackney Health
Authority [1997] 4 All ER 771
.....a judge can choose between two bodies of
expert opinion and to reject an opinion which is
'logically indefensible'.
Sidaway v Board of Governors of
the Bethlem Royal Hospital [1985]
AC 871
..... a doctor has a duty to provide to their patients sufficient
information for them to reach a balanced judgement.
Patients must be informed how necessary a procedure is,
any alternatives, and any common or
serious consequences of it.
Common....?
Serious .....?
Chester v Afshar [2004] UKHL 41;
[2005] 1 A.C. 134; [2004] 3 W.L.R. 927;
[2004] 4 All E.R. 587
It is a basic principle of good medical practice
that consenting adults should be fully informed
and Dr Afshar had therefore violated her right
to choose.
Lord Steyn on fully informing the patient...
"..ensures that due respect is given to the autonomy
and dignity of each patient
.... It allows us to lead our lives
rather than be led along them.
...We allow someone to choose death over radical amputation
or a blood transfusion, if that is his informed wish,
because we acknowledge his right to a life
structured by his own values."
Montgomery v
Lanarkshire Health
Board [2015] UKSC11
Doctors must now ensure that patients are aware of any
“material risks” involved in a proposed treatment,
and of reasonable alternatives,
following the judgment in the case.
the Supreme Court’s ruling outlined the new test:
“The test of materiality is whether, in the circumstances
of the particular case, a reasonable person in
the patient’s position would be likely to attach
significance to the risk, or the
doctor is or should reasonably
be aware that the particular patient
would be likely to attach significance to it.”
GMC’s guidance on consent,
Consent: Patients and Doctors
Making Decisions Together (2008)
Clinical Ethics Framework
Confidentiality
Autonomy/Consent
Beneficence/Best Interests
Non-maleficence/Harm
Justice
Virtue Ethics/Compassion
Patient’s viewpoint
Other considerations/viewpoints
Human Rights
Case study
• Proposal presented to CEAG for routine
HIV testing of all adult patients attending
A&E …..without any individual consent
process.
Routine HIV testing in A&E
• Lambeth
• All patients attending over 16yrs
• No consent …..‘notional’
• Counselling & treatment to positive
patient
Routine HIV testing in A&E
• Clinician
• Aims
• Concerns
• National recommendations
• View of Terence Higgins Trust
• Different views of members of CEAG
Dr Christian, who is the Terrence Higgins Trust National
HIV Testing Week Ambassador, says:
“Testing for HIV is crucial for prevention.
The fact that diagnoses have increased
is encouraging in one sense.
If you get tested and receive a positive diagnosis,
you can now immediately go onto treatment.
Most concerning to me is the fact that one in five people
nationally with HIV do not realise they have it,
so they are putting their own health at risk,
and HIV could unknowingly be passed on to others.”
Routine HIV testing in A&E
• Clinician
• Aims
• Concerns
• National recommendations
• View of Terence Higgins Trust
• Different views of members of CEAG
Recommendations
The group is quite mixed about their support for this
(in a straw poll only 3/15 group members fully supported it).
It is of utmost importance that patients are made aware that they are being tested
for HIV and they are given the opportunity to refuse if they so wish.
.. to ensure that the information about routine testing for HIV in the Trust is much
more accessible to patients
..to ensure that phlebotomists are instructed to remind patients about the routine
tests for HIV at the point of care
..to forward to the group for their review a copy of the patient information leaflet
which should fully outline the blood tests that are being proposed and any other
modified information.
FM invited .. to reflect on today’s discussion and said the group would welcome
seeing any further information on implementation of the testing initiative.