Case and Commentary
Jan 2005
The right of patients to make informed decisions about their medical treatment is a cornerstone of contemporary ethical medical practice. The current Code reflects this right in a number of Opinions including Opinion 10.01, "Fundamental Elements of the Patient-Physician Relationship": "The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives...[and] patients may accept or refuse any recommended medical treatment"; and Opinion 8.12, "Patient Information": "Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions."
Generally, patients are not privy to the specialized knowledge of medicine, and, without help, they are likely to misunderstand their diagnoses and treatment options. Accordingly, physicians and other medical professionals are obliged to use their expertise to help patients make informed decisions about their medical care. As the Code emphasizes again and again, autonomous decision making is a fundamental tenet of good medical care. This point is expressed most directly in Opinion 8.08, "Informed Consent":
The patient's right of self-decision can be effectively exercised only if the patient possesses enough information to enable an intelligent choice...The physician's obligation is to present the medical facts accurately...[and] to help the patient make choices from among the therapeutic alternatives consistent with good medical practice...Social policy does not accept the paternalistic view that the physician may remain silent because divulgence might prompt the patient to forego needed therapy. Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment.
For patients to exercise informed consent (to be autonomous) they must be competent and have decision-making capacity. Determination of a patient's decision-making capacity is an informal judgment by physicians and other health care practitioners about the patient's ability to give informed consent for this decision.
The following generally accepted elements of informed consent can help determine whether Mr. Douglas can give informed consent in this case: (1) the patient must be able to understand the information that he or she receives about his or her medical condition and the likely outcomes associated with all treatment options, including no treatment. (2) The patient must be informed of diagnosis and treatment alternatives with associated risks and benefits (including the risks and benefits of no treatment). (3) The patient must be able to make an uncoerced judgment about the information in light of his or her personal values and goals. Here it is recognized that an individual's "voluntariness," that is, his or her ability to make uncoerced decisions, can be compromised by physical, emotional, or psychological states and by the influence of drugs or alcohol. (4) The patient must be able to communicate his or her wishes with consistency over time.
Mr. Douglas would undoubtedly be judged legally competent, but Dr. Kim has a legitimate concern about whether Mr. Douglas understands the likely consequences of his decision. He seems to know that the surgery will severely limit his activity for some time, but he may not be clear on the likely outcome of refusing surgery.
