Rels 300 / Nurs 3302 October 2014

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COMPETENCE & CONSENT

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Practise QUIZ Case StudyMrs. MacFarlane makes an appointment with her family doctor to confirm whether or not she is again pregnant. With a family of four girls already, the youngest of whom is now in school full days, Mrs. MacFarlane is unsure of her feelings about having another baby. If she could be sure that the fetus would be male, she would definitely carry through with the pregnancy; however, she really doesn’t want to have another girl.Dr. Connors confirms her patient’s pregnancy. When Mrs. MacFarlane asks about prenatal testing, she is told that ultrasounds are commonly used, but that amniocentesis is only offered for medical concerns. Mrs. MacFarlane indicates that unless she can be assured that the fetus she carries is male, she will abort the pregnancy.At the prenatal testing clinic in Halifax, says Dr. Connors, genetic counselors have established a policy which does not allow the use of amniocentesis for purposes of sex selection unless there is concern about a sex-linked genetic disorder. Mrs. MacFarlane says, “That is so unfair.”Dr. Connors recommends that Mr. and Mrs. MacFarlane request an appointment at the prenatal testing clinic to confer with the Director and their ethics consultant. What decision should they reach, and why?

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Instructions:

Quickly test out each moral theory to see which one(s) would be useful for each question.

Decide which moral theory you will use for each question. You must use only one moral theory for each question.

Each answer should use a different moral theory. Do NOT use the same moral theory in more than one answer.

Prepare your answers for questions #1, #2 & #3.

For question #4, use the health care principles to reach a decision.

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Answer these Questions:

1. Imagine that you are the Director of the prenatal testing clinic. Using one moral theory, explain to the MacFarlanes why your clinic has established a policy to refuse amniocentesis for the purposes of sex selection.

2. Imagine that you are Mrs. MacFarlane. Choose one moral theory and use it to outline your argument that the policy is unfair and that the clinic should make an exception for her.

3. Imagine that you are Mr. MacFarlane. Your wife has never expressed sadness at having four girls and no boys before, but you can see how upset she is at the thought of being denied this choice. What will your contribution to the consultation be, and what moral theory will you use?

4. Finally, imagine that you are the consulting ethicist for the clinic. After hearing the moral perspectives of Mrs. MacFarlane, her husband and the Director, you will use the principles of health care ethics to facilitate further discussion and resolve this issue. What will you say?

Recommended On-line resource

Bioethics for Clinicians a series of papers on bioethics published

in the Canadian Medical Association Journal

http://epe.lac-bac.gc.ca/100/201/300/cdn_medical_association/cmaj/series/bioethic.htm

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What is consent?

Consent is the “autonomous authorization of a medical intervention … by individual patients.”

Consent is a process that is ongoing▫ Patients may give their consent to a treatment▫ Patients may refuse to give consent to a

treatment

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Elements of Consent

What are the 3 elements of consent?

1. disclosure of relevant information and its comprehension by the patient

2. patient capacity for responsibility (or ability to come to a decision and live with it)

3. voluntariness (or freedom from force, coercion or undue reward)

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What are the foundations of consent?

Right to be treated as a person

Right to be treated with respect

Right NOT to be treated as an object

What is involved in being a person and being treated with respect?

Capacity for rational thinking Capacity for making our own

decisions Capacity for acting on the

basis of our own decisions

What ethical principle is most closely related to issues of consent?

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Informed consent:the requirement of information

Why must the patient be informed? so that as the patient considers medical options, he or

she has enough information to evaluate options and make a choice

so that the patient knows what alternatives are available

so that the patient understands what is likely to result from each treatment alternative and from refusal of treatment

What does the physician imagine that a patient would want to know before coming to a decision?

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What is the final goal of disclosing information?

• to ensure that the patient’s consent to treatment is the expression of a responsible choice

What is involved in making a “responsible choice”?• the patient is capable of making a choice and living

with the consequences of his or her choices

What counts as a responsible choice?• the patient agrees with the doctor’s recommendation? • the patient is able to take responsibility for his or her

own choices

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Consent must be responsible.Consent must also be voluntary.

What must consent be free FROM in order to count as voluntary?

• has a big reward been promised for those who consent?

• has some threat been made to those who may not consent?

• what would make the consequences of a choice turn into coercion?

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Case of Mary Northern

Mary Northern, 72, has gangrenous feet from severe frostbite and thermal burns. Without amputation, she has a 5–10% chance of surviving and will not be able to walk. With amputation, she has a 50% chance of surviving without being able to walk. Her attending doctors, nurses and judges have all alerted her to the fact her feet are not improving, that she will never walk again, and that she will very likely die if left untreated.

(excerpt from “Conditional Preferences and Refusal of Treatment” by William Glod; HEC Forum; DOI 10.1007/s10730-010-9133-6)

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CAST: Miss Mary Northern; Judge Todd; Judge Drowota; Rev. Sorrow; Nurse

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Aid to Capacity EvaluationJoint Centre for Bioethics, Univ. of Toronto

For each item, indicate YES, UNSURE, or NO to these questions. Is the patient able to understand:1. the medical problem?2. the proposed treatment?3. the alternatives to the proposed treatment?4. what refusal of the proposed treatment would mean?5. the consequences of accepting the proposed treatment?6. the consequences of refusing the proposed treatment?7. Is the person affected by depression?8. Is the person affected by delusions or psychosis?

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Does Mary Northern have the capacity to give her informed consent to or refusal of treatment?

Yes, she has this capacity:

We are unsure

because:

No, she does not have this capacity:

We are still unsure

because:

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Additional features of consent

1. If a patient refuses to consent to a life-preserving medical intervention, can it be initiated anyway to save a life?

2. If a patient suffers a sudden injury and requires treatment to save his or her life, may a physician initiate treatment without consent?

3. If a patient is brought unconscious into the emergency room, how should medical staff proceed?

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2 kinds of consent;lack of (or refusal to) consent

If a patient rolls up her sleeve in a laboratory setting, what will you assume?

If a patient lets you take blood for testing, will you assume that she will accept a blood transfusion?

What is the difference between explicit consent and implied consent?

If a patient refuses to accept a blood transfusion, and the physician orders one anyway, how will that action be judged?

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http://as01.ucis.dal.ca/dhli/cmp_documents/documents/case_studies_2.pdf

Mallette v. Shulman - Ontario

On June 30, 1979, Georgette Malette, a 57 year old woman living in Ontario, was rushed to the hospital following a motor vehicle accident. Mrs. Malette always carried a card with her indicating that she did not want a blood transfusion in the event where she was not able to voice her desires. This card was signed by Mrs. Malette but neither dated nor witnessed.

It Read: 300/330 - appleby 18

“As one of Jehovah’s Witnesses with firm religious convictions, I request that no blood or blood products be administered to me under any circumstances. I fully realize the implications of this position, but I have resolutely decided to obey the Bible command: “Keep abstaining…from blood.” (Acts 15:28, 29).

However, I have no religious objection to use the nonblood alternatives, such as Dextran, Haemaccel, PVP, Ringer’s Lactate or saline solution.”

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NO BLOOD TRANSFUSIONS!

Dr. Shulman discovered that Mrs. Malette was suffering from shock due to severe blood loss. Despite being aware of the card in her wallet, Dr. Shulman decided to perform a blood transfusion and accepted full responsibility for doing so.

As an emergency department nurse, should you support or challenge Dr.

Shulman’s decision?

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What do you think happened?

The Court found that Dr. Shulman had committed the tort of battery by administering medical treatment to Mrs. Malette without her consent…

the card was an accurate, current reflection of Mrs. Malette’s wishes…the right of an adult to refuse medically necessary treatment prevails

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The Law in Canada

An adult person [19 or over in most provinces] who is deemed to be competent may consent to the provision of any treatment OR May refuse consent to any treatment –

even if it is life-saving or life-sustaining

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Practise QUIZ #2 Case StudyA couple from Malta traveled to England for a complicated delivery of their Siamese twin daughters. Jodie and Mary were born on August 8, 2000, joined at the abdomen and with a fused spine. Doctors soon determined that unless the twins were surgically separated both would die. Mary, the weaker twin, whose brain was underdeveloped, would never be able to survive separated from Jodie. Jodie, who was strong and alert, had an 80-90% chance of dying if surgery was not performed. She had a good chance of surviving in the event of surgery, although, in all likelihood she would be severely handicapped and need medical attention throughout her life. In similar cases in the past, the surviving twin has sometimes died within six months of surgery. In other cases neither twin survives. The medical team at St Mary's Hospital, to which the twins were taken, had never done a successful separation of Siamese twins. When the medical team suggested surgical separation, the Parents, who were Roman Catholic, refused on religious and moral grounds to give their consent. The Hospital went to court, pleading that life-saving surgery was in Jodie's best interest, and that saving one of the twins would be morally preferable to losing both. The presiding judge acknowledged the court's duty "to put the welfare of each child paramount," but, nonetheless, concluded that Jodie's right to life outweighed Mary's, thus ruling in favour of the Hospital.

Instructions: Quickly test out each moral theory to see which one(s)

would be useful for each question. Decide which moral theory you will use for each

question. You must use only one moral theory for each question.

Each answer should use a different moral theory. Do NOT use the same moral theory in more than one answer.

Prepare your answers for questions #1, #2 & #3. For question #4, use the health care principles to reach a

decision.

1. Imagine that you are the head of pediatric surgery at the hospital, and you intend to recommend to the parents that Mary and Jodie should be surgically separated. Choose one moral theory and use it to outline your argument that the best choice is surgical separation.

2. Imagine that you are Mary and Jodie’s parents. Explain to the surgeon why you are not willing to consent to an operation to separate the twins. What moral theory will you use for your reasoning?

3. If you were a neo-natal intensive care nurse, what course of action would you support? Choose a moral theory and use it to support your decision.

4. Finally, imagine that the hospital consults their clinical ethicist for assistance. She uses the principles of health care ethics to facilitate further discussion and reach a decision. What will she say?