Transcript Beneficence and Paternalism

Bringing Ethics into Focus
Part 2: Professional Responsibility in Context
AOA Code of Ethics
To keep the visual welfare of the patient uppermost at all times;
To promote in every possible way, in collaboration with this Association, better care of the
visual needs of mankind;
To enhance continuously their educational and technical proficiency to the end that their
patients shall receive the benefits of all improvements in visual care;
To see that no person shall lack for visual care, regardless of his financial status;
To advise the patient whenever consultation with an optometric colleague or reference for
other professional care seems advisable;
To hold in professional confidence all information concerning a patient and to use such
data only for the benefit of the patient;
To conduct themselves as exemplary citizens;
To maintain their offices and their practices in keeping with professional standards;
To promote and maintain cordial and unselfish relationships with members of their own
profession and of other professions for the exchange of information to the advantage
of mankind.
Core Values of the AOA Code
• A survey of the AOA’s code, typical of a
mixed form, reveals a set of core values
animating the code. These values include:
 Patient Welfare
 Eye Health/Vision
 Professionalism
 Collegiality
Operative Principles
• Beneficence: actions or practices are right
insofar as they produce good consequences.
 Expressed negatively as Nonmaleficence: Do No
Harm).
• Autonomy: actions or practices are right insofar
as they involve respecting the autonomous
choices of individuals.
• Justice: The principle that actions or practices
are right insofar as they treat people in similar
situations equally.
Beneficence and Paternalism
• Mr. Lawson, a longtime patient of Dr. McMasters, has lived with
Type II diabetes for more than a decade. Each year, during his eye
exam, Mr. Lawson refuses dilation, part of the recommended
standard of care for patients with diabetes. This year, Dr. McMasters
observed signs of diabetic retinopathy during his standard
examination. Though McMasters explained the possible implications
of this observation to Mr. Lawson, the patient still steadfastly refused
dilation. Dr. McMasters considers it his duty to follow the
recommended care standards, and is considering refusing to
prescribe vision correction for Mr. Lawson unless he consents to the
dilation and examination.
Beneficence as a Moral Perspective
• Beneficence has an important historical role in
medical ethics as the core of the Hippocratic
Oath.
• The focus of the principle of Beneficence is on
the consequences of the actions of the
practitioner for the health and welfare of the
patient.
• The weight in the decision-making process is
thus placed on the judgment of the practitioner.
Problems with Beneficence
• The principle of Beneficence, while relatively
non-controversial, is not as straightforward as it
first appears.
• There are important questions that need to be
resolved before a practitioner can be confident
that they are acting beneficently.
 Subjective vs. Objective Estimates of Benefits
 Medical vs. Other Personal Benefits
 Conflicting Goals within the Medical Sphere
Beneficence and Paternalism
• Paternalism: action taken to benefit a person
against her will.
 Strong: taking such an action even though the person is mentally
competent.
 Weak: taking such an action when a person is known or
suspected to be incompetent.
• Hippocratic ethics are often taken to justify both
forms of paternalism. This is one of the reasons
many contemporary medical ethicists are
moving away from the Hippocratic perspective
toward perspectives the emphasize respect,
autonomy, truth-telling, and fidelity.
Autonomy and Informed Consent
• Dr. Joan Paulsen had a problem. Her good friend Marcia had
brought in her elderly mother for an eye exam during which Dr.
Paulsen found advanced diabetic retinopathy in the periphery of
both eyes. Typically, she would immediately report these findings to
the patient, prepared to discuss the diagnosis and treatment options,
but Marcia had told her that her mother’s emotional and mental
states were very fragile. In light of this Marcia had requested that
any negative information about her mother’s ocular health be
withheld from her, and instead reported to Marcia. In her
conversation with Marcia’s mother, Joan had not noticed any sign of
fragility. Now she wondered how to proceed.
Autonomy as a Moral Perspective
• Autonomy is a moral perspective that frequently
conflicts with beneficence, and thus with the
Hippocratic perspective.
• The beneficence perspective gives a great deal
of prominence to the consequences of actions.
Autonomy, on the other hand, places the
emphasis on the claims that a patient has on a
practitioner.
• These claims can be articulated as rights the
patient has relative to the practitioner or as the
duties the practitioner has to the patient.
The Conflict: Informed Consent
• “Informed Consent” refers to obligations a practitioner
has to provide her patient with all relevant information
about her health and treatment options.
 This obligation allows the patient to make appropriate decisions
about their care.
• The Beneficence perspective can provide some
justification of informed consent, but only to the extent
that the consent benefits the patient.
• The Autonomy perspective, on the other hand, requires
that all meaningful information be disclosed to the
patient, even when it is believed that the disclosure may
be harmful.
Standards for Disclosure
• Fully informing a patient is frequently, if not
always, impossible. The general obligation is to
provide adequate information.
• How can a practitioner determine when they’ve
met their obligation?
 The Professional Standard: what would similarly
situated colleagues do?
 The Reasonable Person Standard: what information
would a reasonable person want?
 The Subjective Standard: what information fits the life
plans and interests of the individual?
Justice and Resource Allocation
• Faced with declining insurance reimbursements and
increasing practice costs, Dr. Ball fears that she may be
forced to discontinue her participation in the statewide
insurance program for the economically disadvantaged
and uninsurable. Though one of her original motivations
to become an optometrist was her conviction that
providing quality care to underserved populations was
the right thing to do, the economic implications of this
choice seemed increasingly dire. What was more
important, maintaining her principled commitment to the
less fortunate, or pursuing her own fortune?
Justice as a Moral Perspective
• Justice is another moral perspective that seems
to conflict with implications of the principle of
beneficence. Most obviously, beneficence
seems to lack a notion of moral community.
 The autonomy perspective seems to fare little better.
• The perspective of justice corrects this
inattention to the broader social implications of
health care by raising the question of the duties
medical professionals have to third parties.
The Problem of Scarcity
• Scarcity of medical resources is an obvious concern of
the justice perspective in medical ethics. One form of
scarcity is that of access to care.
• Despite the amazing amount of money spent each day
on health care in this country (~3.5 billion dollars/day),
significant numbers of our citizens lack even basic
insurance coverage. In 2000, 14% of the U.S. population
was completely without coverage.
• At the same time, practitioners are increasingly pinched
by the insurance industry (public and private), and by
rising costs, exacerbating access scarcity.
Justice in Allocation
• The justice perspective requires practitioners to balance
their obligations to themselves and their patients against
their obligations to those who lack the means of access
to appropriate care.
• Clearly, there are limits to this balancing act.
practitioners may lack the means to accurately calculate
the balanced benefits. There are also problems posed by
the conflicts between the obligations of justice and those
that flow from their patients.
• In response, some people have argued that practitioners
should be exempt from considerations of justice, but that
seems too extreme.
Balancing Values and Principles
• Despite the conflicts between the various perspectives
we’ve considered, each of them has their place in an
individual practitioner’s attempts to embody the values
outlined in the AOA code.
• An important part of being a responsible optometric
professional is reflecting on the different implications
these principles have for the values you should embody.
• Ultimately, it is the individual practitioner’s responsibility
to reflectively negotiate the conflicts between principles
and across values.