Philosophy 242 MEDICAL ETHICS SUM2014, M-F, 9:40-10:40, SAV 156 INSTRUCTOR: BENJAMIN HOLE OFFICE HOURS: M-F, 10:40-11  EMAIL: BVHOLE@UW.EDU

Next week Notes Movie in-class on Tuesday (no clicker quiz) Dworkin on Monday Dworkin directly criticizes Mill’s claims about autonomy and anti- paternalism Schedule Sound and Fury (in-class movie) “Paternalism,” Gerald Dworkin “Ethical Relativism in a Multicultural Society,” Ruth Macklin  “Defending Deaf Culture,” Robert Sparrow

Agenda Clicker Quiz Chapter 5 – “Informed Consent” (mini-lecture) Discuss case studies Special attention to Dax’s Case (and dialogue with Robert Burt) When is the “end of the day” for informed consent? Only discuss the others if we have time… Please set your Turning Technology Clicker to channel 41 Press “Ch”, then “41”, then “Ch”

Discussion Be thoughtful about: Priority for: depth versus breadth clarification versus argumentation Priority for: Direct engagement over new points New voices over old ones

Therapeutic privilege According to the textbook, a credible and severe threat of harm or force to control another is known as Manipulation Enticement Coercion Waiver Therapeutic privilege

Therapeutic privilege Consent to treat Waiver Substituted competence According to the textbook, the withholding of relevant information from a patient when the physician believes disclosure would likely do harm is known as Coercion Therapeutic privilege Consent to treat Waiver Substituted competence

From a strictly Kantian viewpoint, therapeutic privilege is Always permissible Respectful to persons Never permissible Necessary

Informed Consent “The action of an autonomous, informed person agreeing to submit to medical treatment or experimentation.”

Case: Sexual Ethics “Mr. Supervisor makes a series of increasingly less subtle sexual overtures to Ms. Employee. These advances are consistently and firmly rejected by Ms. Employee. Eventually, Mr. Supervisor makes it clear that the granting of ‘sexual favors’ is a condition of her continued employment.” Ms. Employee agrees to grant sexual favors to Mr. Supervisor. Has Mr. Supervisor has gained Ms. Employee’s informed consent? Thomas Mappes, “A Liberal View of Sexual Morality and the concept of Using Another Person”

Conditions of Informed Consent The patient is competent to decide. Competence: the ability to render decisions about medical interventions She gets an adequate disclosure of information. She understands the information. She decides about the treatment voluntarily. She consents to the treatment.

Courts and legislatures have mandated the disclosure of: The nature of the procedure The risks of the procedure The alternatives to the proposed procedure, including the option of no treatment The expected benefits of the proposed treatment

Informed Consent Waiver—The patient’s voluntary and deliberate giving up of the right to informed consent. Therapeutic privilege—The withholding of relevant information from a patient when the physician believes disclosure would likely do harm

Informed Consent & Ethical Theory Utilitarianism Kantian Deontology Bentham: it always depends … Mill: informed consent is required Informed consent is always required A waiver of consent is probably permissible …

Informed Consent & Dax’s Case In Dialogue with Robert Burt

Robert Burt “The place at which I get troubled or confused is what exactly follows if we embrace this important norm of autonomy… One version of autonomy says: well, it's the physician's job, like it's anybody's job who needs to respect autonomy, to say to a patient, "What do you want?"; the patient says "I want A, B, C," or "I don't want A, B, and C," and then it's just the physician's job to implement that. That is a possible interpretation of the law and way of proceeding.” Burt claims this view is unsatisfying because it is the responsibility of the physician to ask “why” and examine the reasons for refusing treatment.

Dax Cowart “John Stuart Mill, the English philosopher, in his essay On Liberty, came down on the side of the right to self-determination by dividing acts into those that are self-regarding and those that are other-regarding in nature. Mill concluded that when the act is self regarding in nature, the individual should be left to make his or her own decisions. That is precisely my view.” “In a medical context, I am saying that before a physician is allowed to pick up a saw and saw off a patient's fingers or pick up a scalpel and cut out a patient's eyes, we must make sure that the physician has first obtained that patient's informed consent. I always like to stick the word "voluntary" in there-informed and voluntary consent-because consent that is obtained through coercion or by telling half- truths or withholding the full measure of risk and benefit is not truly consent.”

What is the “end of the day”? Burt: “Now come the end of the day, yes, it's your life, it's not my life. But the question is, When have we reached the end of the day? When may we terminate this conversation so that I believe that the choice that you're making is as considerate a choice as I think it is morally obligatory for you to make?” Dax’s Case “end of the day”? Immediately after the accident After he gets to the hospital and doctors fully explain all the options to the best of their knowledge After B, plus doctors examining his reasons for refusing treatment through discussion After C, plus being found mentally competent by medical professionals After D, plus trying some of the treatments … After Dax has been treated and goes home

When should be the “end of the day” in Dax’s case? Immediately after the accident After he gets to the hospital and doctors fully explain all the options to the best of their knowledge After B, plus doctors examining his reasons for refusing treatment through discussion After C, plus being found mentally competent by medical professionals After D, plus trying some of the treatments … After Dax has been treated and goes home

Case Studies “Informed Consent”

Informed Consent or Not? A woman consents to be put on a feeding tube to maintain nourishment. However, later that night she “becomes disoriented and seems confused about her decision to have the feeding tube”. The next day the patient is lucid, says she does not remember being disoriented or confused, and again consents to the feeding tube. Has the woman given her informed consent? Should she be judged competent? Should her final agreement to the procedure be sufficient to establish informed consent, or should her earlier waffling and confusion also be taken into account?

The woman has given her informed consent Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree

Informed Consent and Organ Transplants “(AP) A woman in her 30s who is one of the four organ transplant patients (who became) infected by HIV and hepatitis (because of the transplant) was not told that the infected donor was high risk” “The donor had engaged in high-risk behaviors, according to a screening questionnaire, but standard testing showed the donor did not have AIDS or hepatitis C.” “If Jane Doe had not become infected with HIV and hepatitis after her transplant, would the failure of the donor network and the university to fully inform her about the donor have been morally wrong?” For fully informed consent, did they need to disclose the risky behavior?

Jane Doe was given her informed consent Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree

Adolescent Informed Consent “a 14-year-old youth was brought to the pedantic emergency department by his mother for evaluation for altered mental states” “Given the ongoing epidemic of West Nile virus at the time of presentation … the mother was absolutely insistent that a spinal tap be performed” “Because of the assurance of confidentiality, the patient disclosed that he had bought a large amount of dextromethorphan…” Who, if anyone, in this scenario should be allowed to give informed consent to treatment (or no treatment)? Should the physician regard the 14-year-old as a mature minor? What actions should the physician take if she regarded him as a mature minor?

Who, if anyone, in this scenario should be allowed to give informed consent to treatment (or no treatment)? 14-year-old Mother Other