Transcript Consent

COMPETENCE & CONSENT
Rels 300 / Nurs 330
2 October 2014
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Practise QUIZ Case Study
Mrs. 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.
2.
3.
4.
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.
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.
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?
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?
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Recommended On-line resource
Bioethics for Clinicians
 a series of papers on bioethics published
in the Canadian Medical Association
Journal

http://epe.lacbac.gc.ca/100/201/300/cdn_medical_association/cmaj/series/bioeth
ic.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?
[coercion = persuade or dissuade by force]
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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 Evaluation
Joint 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:
No, she does not have
this capacity:








We are unsure
because:
We are still unsure
because:
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Additional features of consent
1.
2.
3.
If a patient refuses to consent to a lifepreserving medical intervention, can it
be initiated anyway to save a life?
If a patient suffers a sudden injury and
requires treatment to save his or her life,
may a physician initiate treatment
without consent?
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:
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NO BLOOD TRANSFUSIONS!
“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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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 Study
A 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?