Violation of the Patient’s Autonomy?: Is that Ethical?
Patient autonomy is the ethical principle which represents that a patient who has the capacity to understand their medical condition and the risks and benefits of some action upon them, has the ethical right, under most circumstances, to make that decision for themselves and expect the physician to abide with their request.
But that is “under most circumstances”. I want to present two scenarios where a patient has stated “stop! I don’t want…” The question I pose to my visitors is whether a physician can ignore that request in each of the scenarios and if so why or why not should the patient’s request be followed or not followed. When do standards of medical practice trump a patient’s request? Standards of medical or surgical practice are specific behaviors, based on scientific literature but also based on the consensus of physicians about certain diagnostic or therapeutic actions and also on common behaviors or actions of doctors where they practice and which the profession of medicine place upon physicians as the physicians carries out their care of their patients. In this regard, if there is a difference between the two cases, what is the difference? ..Maurice.
Scenario 1:
Brain surgery of lesions is often performed on conscious patients to establish safe dissection around motor and sensory areas. A patient with skull opened and brain exposed demanded the surgeon to stop the operation at once despite understanding the consequences of fully terminating the surgery at this point and leaving the skull open. Instead of stopping, the surgeon had the patient anesthetized to allow proper closure of the skull thus was violating the patient's demand. Is what the surgeon did ethical?
Scenario 2:
An adult Jehovah’s Witness patient because of acute massive bleeding which cannot be rapidly stopped requires life saving blood transfusion but is awake and refuses blood transfusions based on the patient’s religion. The patient is informed that with the transfusion, the patient will live and the underlying bleeding problem can be resolved with no long term medical consequences. Without the transfusion, the patient could most likely die. The patient still refuses but the physician, as the patient is beginning to lose consciousness, violates the patient’s autonomous demand and begins the blood transfusions. Is what the physician did ethical?
posted by Maurice Bernstein, M.D. @ 5:01:00 PM
8 comments
8 Comments:
I see no way a surgeon could ethically leave a skull open and a brain exposed- despite what the patient might be saying under stressfull circumstances...
The Jehovah Witness/ blood question seems more complex- although we might not agree with their belief about blood products- I am inclined to say we should respect/honor that belief...
thank you for your postings..
In scenario 1, I assume the surgeon had no indication prior to surgery that the patient might request termination. The patient is in a traumatic situation, and his judgment may be influenced by the circumstances. I think what the surgeon did was ethical.
In scenario 2, I would need more details on the situation to decide. The most difficult scenario would be that the patient came into an emergency room, the physician had never seen the patient before, there were no patient records, and, in particular, the patient had not previously signed an advance directive with regard to transfusions. I actually think it would be ethical for the physician to allow the patient to die in that situation, assuming the patient is not a minor.
If the patient was admitted to a hospital and this happened during the patient's stay, then someone would be at fault for not having clarified in advance how to handle the possibility of this event. Prior to surgery, for example, a Jehovah's Witness can be informed of the risks and can state quite clearly that he or she is prepared to die rather than receive a transfusion. It would not be unethical to allow such a patient to die when the circumstances have been anticipated. I suspect, however, that most surgeons would not want to operate on such a patient.
Maurice, I fail to see the ethical quagmire in the 2 cases. The surgeon is not ethically bound to leave a patient in jeopardy of his life. The patient consented (presumably) to surgery and does not have the right to abort it midstream, leaving his brain open to the air. This is an different scenario from a patient who asks that a colonoscopy be stopped before the procedure has been completed. In this case, the physician has not ethical right to continue, as terminating the procedure early does not create direct risk of illness and injury to the patient.
In the 2nd case, the physician is ethically bound to observe the competent patient’s wishes to avoid blood products, even at the risk of life. Transfusing the patient is an ethical violation.
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Michael, I doubt there is any ethical "quagmire". I can see, however, there might be a misunderstanding by some about the power of a patient's autonomous order. This is what I was trying to explore.
I agree with your example of colonoscopy, though an evaluation by the colonoscopist would first be necessary if the patient was at the time sedated and whether the patient's request could be evaluated as a "considered request" under these conditions. Obviously, if such an evaluation was equivocal, the colonoscopy should be terminated.
Let's try now the case of a vasectomy where the patient tells the urologist that he changed his mind, he wants to remain fertile but unfortunately both tubes have just been cut. Should the urologist close up or begin the process of attempting to surgically reverse the vasectomy? Oh yes.. and there is a scheduled right nephrectomy for kidney cancer ready for surgery in the next operating room and maybe more pre-ops waiting. ..Maurice.
Maurice, I think the scenarios in your comment are slightly too hypothetical, but I will respond. No the urologist is not obligated to reconnect, particularly with OR cases in waiting. Such a patient already would have signed a consent indicated he knew that the procedure was irreversible. Agree?
Well, not exactly hypothetical since for one reason or another patients are, despite so-called "informed consent" not fully aware of what they signed, the significance of what they signed and finally the significance of professional "standards of practice" which could potentially trump a patient's autonomous request which the patient might have considered absolute. ..Maurice.
Hi Maurice, I think with respect to vasectomy, the consent process is extremely straightforward. Men are told the minor risks and the irreversibility of the procedure. There's not much complexity or nuance as exists with other treatments that require informed consent. I agree with the subtext of your comment that informed consent has often become a formality.
I think as a part of the "informed consent" a patient getting a vasectomy or other similar procedure should be told in advance that a female nurse is usually used to "assist", which from what I hear means holding the penis or just watching. I know it would change my mind or allow me to have a part in planning the procedure. Especially knowing that it's well documented that it can be done by the doctor alone.
This may seem off topic a little but I think it is relevant because often a procedure may begin and a patient may think everything is under control and then suddenly a surprise and unwanted "visitor" or "assistant" makes an appearance. I personally would want to stop the procedure until this unwanted assistant has left. The doctor would have to decide whether to continue against the patient's will, refuse to continue without the assistant or tell the assistant to leave. I understand that it's probably uncommon for an assistant to arrive after the procedure has begun but I don't imagine it's unprecedented.
We also know how common it is for a patient to be afraid to speak up once a procedure has begun. If a patient is told beforehand that a nurse will be there to hold his penis the whole time (for example) he might want to make a request or cancel the procedure. Whether he objects or keeps his mouth shut he still loses his sense of autonomy when she arrives.
I won't even begin the discussion about all the uninformed things that happen to patients after being sedated. That's a complete loss of control, and most often patients don't know what will happen to their body before it happens or after. Is that really informed consent or the right to autonomy?
Lee
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