Dr Idara C. Eshiet

This is a basic fundamental human right. It is the most fundamental principle underlying all health-care ethics. This is the patient’s right to make their own decisions concerning their healthcare after being properly educated and informed.( see American College of Physicians Ethics Manual, 2,15).

In a health care setting, the principle of Autonomy translates into the principle of informed consent: You shall not treat a patient without the informed consent of the patient or his or her lawful surrogate, except in narrowly defined exceptions. In order to affirm autonomy, the physician has to make every effort to discuss treatment preferences with patients and ensure that they are documented in the patients’ charts.

It is the responsibility of the physician to always act in the best interest of the patient. This requires us to do good, or what will further the patient’s best interest. The following secondary principles come under Beneficence: a. Prevent infliction of needless pain b. Prevent killing c. Prevent incapacitating others.

This requires us, other things being equal ; to avoid harming the patient, or what would be against the patient’s interest. The following secondary principles come under non- maleficence: a. Do not kill b. Do not cause needless pain c. Do not incapacitate others ( Beaucamp and Childress) Note that these principles can be met by doing nothing.

In summary, the principle of beneficence means that unless there is sufficient reason not to, one has an obligation to do those acts that are likely to do more good than harm. The principle of non-maleficence means that unless there is a sufficient reason not to, one has an obligation not to do those acts that are likely to produce more harm than good.

This means acting without a person’s consent or overriding a person’s wishes, wants, or actions, in order to benefit the patient or prevent harm to him or her. Paternalism overrides a competent patient's explicit wishes, and is generally rejected because it violates autonomy; falsely presumes independent knowledge of what is best for the patient; and falsely presupposes that there is a clear, objective set of values governing such decisions. ( AMA code, 8.08)

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter's death). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars

Competence is a legal term Only a court can determine that a patient is incompetent. All adult patients are deemed competent unless specifically proven otherwise. Physicians can determine whether or not a patient has the capacity to understand his / her medical condition.

The physician determines the capacity of the patient to comprehend his/ her medical problems based on whether there is an organic delirium due to a medical condition such as an electrolyte imbalance, hypoxia, drug intoxication, meningitis, encephalitis, or a psychiatric disorder. This is done largely based on a neurological examination testing memory, comprehension, reasoning, and judgment.

The patient must be able to comprehend information and is able to know that he or she is authorizing medical treatment, is able to understand the effects of treatment, options in terms of health, life, lifestyle, religious beliefs, values, family and all other factors bearing on treatment decisions. The relevant competence is competence to make the specific treatment decision at hand. Conditions for competence

A minor is said to be someone under 18 years. Minors are not considered competent to make decisions concerning their healthcare. Only a parent or a legal guardian can give consent for a minor. Note: In emergency situations, consent in implied.

The neighbor of a 14- year old boy brings him to the emergency department after sustaining a laceration to the scalp from head trauma. You evaluate him and determine that suturing of the scalp will be necessary. Which of the following is the most accurate? a. He is an emancipated minor; the patient can give consent b. The neighbor can give consent c. Wait for the consent of at least one parent d. Wait for the consent of both parents e. Consent is not necessary in this case

Although parents and guardians can give consent for procedures and therapies for minors, there are certain exceptions to this rule. In areas of : 1. Prenatal care 2. Contraception 3. Sexually transmitted diseases 4. Substance abuse

A 15- year old girl comes to the clinic for dyspareunia and a vaginal discharge. On speculum examination you find she has cervicitis. The pregnancy test is negative. The infection is modest and there is no emergency. What is the appropriate action to take? a. Ceftriaxone/ azithromycin now in a single dose b. Make at least a “ good faith” effort to notify her parents and treat her c. Wait to inform at least one parent d. Treat only if the patient agrees to inform her parents e. Treat her now and inform the parents later.

A 16- year old female comes to the clinic after missing a period. Her pregnancy test is positive and she wants to start prenatal care with you. She is adamant that you keep the pregnancy confidential from her parents. What should you tell her? a. “ I will give you the care you need and keep it confidential”. b. ” I will not mention it to your parents unless they ask. I can’t lie”. c. “ I am sorry, but I must tell them”. d. “ I will not tell your parents, but I must inform the father of the baby”.

A small number of minors, mostly at older ages such as 16 or 17, may be considered ‘emancipated’ or freed from the need to have parental consent for medical care. Criteria: 1. Married 2. Self- supporting 3. Living independently 4. In the military 5. Parent of a child they themselves support.

1.The physician must consult the patient’s living will if there is one 2. If there is no living will or the living will provides no clear guidance, the physician must consult the surrogate decision maker: either one designated by a durable power of attorney, or a family member. In order of priority: healthcare durable power of attorney, or guardian; spouse; children of legal age; other relative, close friend, or caregiver.

1. Principles of medical Ethics by Beauchamp and Childress 7 th Edition 2. Resolving Ethical Dilemmas Bernard Lo 5 th Edition 3. American Medical Association code of Medical Ethics, 1996