Ethical,_Legal_and_Professional_Issues_in_Health_Care.

Ethical, Legal and Professional Issues in Health Care. The author of this essay is a second year student Operating Department Practitioner (ODP), currently training in a large and busy theatre suite. He has been working in a medical role within the Armed Forces for the past eight years. The Oxford English Dictionary (1999) describes an autonomous person as being “self governing”, or able to make ones own choices about factors concerning their lives. The empowerment of patients is a concept which is now a cornerstone of modern medical care. The aim of this essay is to discuss the issues surrounding patient autonomy and directly relate them to the role of the ODP. By utilising the authors’ knowledge and experience strongly supplemented by published evidence, the following points are discussed: 1. Patient autonomy. 2. Autonomy and consent. 3. What is valid consent' 4. Autonomy vs. Paternity. Patient autonomy. The term ‘caring for a patient’ is difficult to define, as it means different things to different people and be can provided on a number of levels. Whether the provision of care is task orientated, such as bathing, feeding and treatment, or more spiritually based, such as listening, guiding and emotionally supporting, all forms are valid and important. Barnhart et al (1994) describes a care provider as one who responds to the unique needs of an individual, implying that all patients’ needs are different and should be identified in initial assessment. Mallet & Bailey (1990) enforce this when suggesting that the provision of effective individualistic caring is dependant on an accurate assessment of the patients’ health status and the adherence to the wishes of the autonomous individual. According to Boyd et al (1997), autonomy derives from the Greek word autonomia, which literally translates as “self rule”. As already mentioned, it is the capacity to make measured decisions on oneself, and to act on the basis of those decisions accordingly. The encouragement of autonomy is an important principle in modern medicine and stems from a variety of moral and ethical principles, including utilitarianism and deontological theory. Utilitarianism is described by Boyd et al (1997) as a consequentialist method of attempting to create the greatest amount of good for the largest number of people. Ascension Health (2005) mentions the most noticeable theory as being the deontological philosophy of Immanuel Kant from the 18th century. In Kant’s ethics, autonomy is equated with determination, and individuals are said to be autonomous when their actions are truly their own. Patient autonomy is therefore referring to the capability and rights of an individual to have input in the decision making process concerning their own medical treatment. The Department of Health (2001) enforces the importance of this statement when stating that; “Patients have a fundamental legal and ethical right to determine what happens to their own bodies…” The principlist approach to medical ethics by Beauchamp & Childress (1994) suggests that all ethical problems in medicine can be analysed using a four-pillared framework which encompasses the principles of autonomy along with beneficence, non-maleficence and justice. Parker & Dickenson (2003) suggests that beneficence can be described in plain English as simply acts of kindness, mercy and charity. However, Boyd et al (1997) add more substance to the definition by explaining that beneficence is actually a moral obligation to do good, rather than just being good natured. In practice, the term translates as doing what is considered in the benefit of the patient. The AODP code of conduct enforces the importance of beneficence in the ODP when stating that the practitioner should: “Carry out all roles and responsibilities in such a way as to promote and protect the rights and health of the patient.” The principle of non-maleficence asserts an obligation to not intentionally inflict harm on the patient, (Parker & Dickenson, 2003). The author believes that a good example non-maleficence being exercised in operating theatre is when the scrubbed practitioner checks the patients consent form prior to operation. This acts as a safeguard to ensure that the correct operation is being performed to the correct patient and that any drug sensitivities are being considered. The checking of a valid consent form before procedure is a legal responsibility of the registered practitioner, as the AODP code of conduct states: “Let no act or omission on his/her part place at risk the care afforded to the patients.” The subject of consent is interwoven with that of patient autonomy, and will be discussed later in the piece. Justice is a moral obligation to be just and fair, according to many moral theories, (Howard & Bogle, 2005). The concept of justice by Beauchamp & Childress (1994) is difficult to decipher clearly, but when referring to the theories of Aristotle, they mention how equals are to be treated equally, and un-equals are to be treated unequally in relation to their morally relevant inequalities. The author of this essay feels uneasy about the relevance of this theory in healthcare, and prefers to believe that its significance lies more with the application of law and the enforcement of patients’ rights. Clarke & Jones (1998) mention the rights of a patient by law as follows: 1. To give or withhold consent. 2. To receive information. 3. To have access to records. 4. To complain. To enforce patients’ awareness of these rights and to provide answers for many frequently asked questions, the National Health Service (NHS) has produced an in depth publication called Your Guide to the NHS, (the guide). Previously called the patients charter, the guide also outlines health tips, and protocols for utilizing the NHS effectively. It also hands some responsibility regarding patient care to the patients themselves. For example, the guide states: “Care for yourself when appropriate. (For example, you can treat yourself at home for common ailments…)” This is just one of a number of points which are designed to educate and empower the patient and encourage patient autonomy. In the operating theatre environment, as the patients advocate, the practitioner can enforce the patients’ wishes, thus fulfilling patient autonomy. The author of this essay recently acted as the advocate to a 74 year old lady who was about to be anaesthetised prior to a routine orthopaedic operation. A general anaesthetic would be required, and a Laryngeal Mask Airway (LMA) was the anaesthetists’ airway of choice. Due to the ill-fitting nature of her full set dentures, they would need to be removed to facilitate placement of the LMA. However, the patient confided with the author that she had always been self conscious of her dentures, and demanded that she did not spend any more time than absolutely necessary without them. Acting as an advocate to the patients’ wishes, the author agreed that the dentures would be removed at the last possible moment, and would ensure that the recovery staff replaced them as soon as it was safe to do so. As her request was taken seriously and adhered to, this allowed the patient to remain autonomous even whilst incapacitated. Autonomy and consent. In order for a patient to be autonomous in the operating theatre, consent is obtained from the patient before a procedure is carried out. Beauchamp & Childress (1994) describes an autonomous being as: “One who acts freely with a self chosen plan… one free from both controlling influences by others and from personal limitations that prevent meaningful choice, such as inadequate understanding.” In the operating theatre environment, the patients’ “self chosen plan” and “adequate understanding” are adhered to by obtaining consent. Farsides (2003), states that consent derives from and promotes the principle of autonomy, and suggests that in individual who is capable of making informed choices is therefore responsible for their outcomes. Mallett & Bailey (1997) describe consent as an individuals’ freely given agreement to treatment, based on having received information about and having a full understanding of what is proposed. Consent is essential in the operating theatre, as it is the patient’s agreement for the health professional to provide care for them. Any treatment carried out on the patient without consent can lead to a charge of assault and battery being brought against the carer, (Howard & Bogle, 2005). What is valid consent For consent to be valid, the Department of Health (2001) states that the patient must: 1. Be competent to take the particular decision. 2. Have received sufficient information. 3. Are not acting under duress. A patient is deemed to be competent when they have sufficient emotional, physical, and mental capacity to make an informed choice. Boyd et al (1997) suggest that a competent individual is one who has a broad understanding of the procedure itself, its consequences, and the consequences of not having the treatment. Capacity is, however, almost impossible to measure entirely, and the British Medical Association (1993) accepts this. They suggest that, unconscious patients apart, all patients, including young children and mentally handicapped patients, can have some degree of input when planning the outcome of their care, usually with the guidance of a parent or guardian. This is enforced by The Law Commission Report for Mental Incapacity (1995), which states that an incapable patient is defined as one who is, due to mental disability, unable to make a decision on the matter, or unable to communicate their decision. The rights of children are enforced in a similar fashion. Mason & McCall Smith (1998) suggests that when a child is deemed competent to understand the nature and implications of the treatment, their consent alone is valid. However, although the British Medical Association (1993) agrees with this in principle, they state that it is desirable for parents to be involved in the consent process if the treatment has serious implications, and the doctor should encourage the young person to agree to parental involvement. In the authors’ opinion, this is one of the areas which contradicts the concept of encouraging pure patient autonomy, and veers towards paternalism. Mason & McCall Smith (1998) claims that merely disclosing the information about the treatment to the patient is not enough to fulfil the consent process. The practitioner must be absolutely certain that the patient has a full understanding of the information they have received. This can be achieved by talking in plain English, avoiding unnecessary jargon, and encouraging the patient to ask questions. The author has often witnessed one particular anaesthetist who has an impressive method of ensuring the patient sufficiently understands the procedure. After the pre operative assessment and the talk through of the anaesthetic, the anaesthetist requests the patient to, in their own words, relay back him the information they have just received before signing the consent form. This convinces both the anaesthetist and the patient that everything is sufficiently understood. A patient should be able to give consent voluntarily without unfair coercion, (Parker & Dickenson, 2003).However, Boyd et al (1997) states that the law does not prohibit a patient seeking advice from others, and any persuasion from a third party is deemed acceptable providing that it does not overbear the independence of the patients decision, although the law would have to consider the relationship between the ‘persuader’ and the patient. The author of this essay is unsure of exactly what this rather vague statement implies, and wonders if a family member would be in a more or less appropriate position to influence the patient than the practitioner. Would, for example, influence from the operating surgeon be over paternalistic' Once again, questions regarding paternalism come to the foreground, suggesting that perhaps neither autonomy nor paternity are mutually exclusive when establishing the best interests of the patient. Autonomy vs. Paternity. According to Boyd et al (1997), paternalism is generally considered as the control of other peoples lives under the guise of it being in their ‘best interest’ but regardless of their wishes. The author feels that this description, if accurate, makes paternalism an almost polar opposite of autonomy, and as autonomy is considered by Beauchamp & Childress (1994) as the cornerstone of medical ethics, this must therefore damn the relevance of paternalism in healthcare. However, Boyd et al (1997) argues that respecting a patient’s autonomy is not necessarily the same as providing for his welfare. Quill & Brody (1996) state that although the emphasis is now firmly aimed towards patient autonomy, years ago it was deemed acceptable for a physician to make decisions on the patients’ behalf, and therapeutic privilege would often be exercised. Parker & Dickenson (2003) describe therapeutic privilege as the physician consciously withholding information which may psychologically damage or needlessly distress a seemingly capable patient. Patients with serious illnesses would not necessarily be told certain facts about their conditions, and information would be withheld if it was thought to possibly upset the patient. These are, in the authors view, the extreme of paternalism which of course has no place in modern medicine. However, avoiding causing ‘needless distress’ to the patient is a fine example of non-maleficence, which alongside autonomy, is a cornerstone of the principlist approach to medical ethics by Beauchamp & Childress (1994). This leads to the obvious conclusion that neither absolute autonomy nor absolute paternity can be of benefit to the patient, and that a blend of both is required to provide the most effective care. Konrad (1983) argues that because illness necessarily diminishes the patients’ autonomy, medical paternalism aimed at restoring the patients’ health, and therefore his autonomy, is justifiable. Quill & Brodie (1996) enforce this view when stating that the further a person is from being a rational self ruler, the more paternalistic behaviour is appropriate. The author believes that in the operating theatre environment it is virtually impossible for a patient to be entirely autonomous. Although risks and choices of the anaesthetic and surgical procedure can be discussed at length beforehand, the practitioner will undoubtedly encounter situations in which they will have to act outside of the previously discussed boundaries, and justify his actions as being in the patients ‘best interest’. For example, the patient may not have consented beforehand to the insertion of an additional intravenous cannulae, however if existing IV access is compromised during the operation, replacement is essential for the welfare of the patient and maintenance of safe anaesthesia. As an autonomous being himself, the practitioner should be expected to perform this essential care with a clear conscience, and without the fear of repercussion. This essay has successfully highlighted some of the many issues surrounding Patient autonomy, and related them to the practice of ODP’s in operating theatre. This was firstly achieved by explaining what exactly patient autonomy is and how it affects the manner in which the practitioner provides care. Secondly, it has been identified that in order for a patient to be sufficiently autonomous in the operating theatre, thorough and documented informed consent is required. When discussing consent, the importance of valid consent was mentioned, outlining what constitutes valid consent and which patient groups are most problematic. Finally, the subject of paternity was discussed in an attempt to discover what it is, how it stands against autonomy, and whether or not it has a place in modern healthcare. The author believes that paternity does have a place in modern healthcare to a certain degree, and feels that the emphasis placed on patient autonomy can at times go too far. Although autonomy is obviously important and is quite rightly considered one of the pillars of medical ethics, the author feels that if enforced absolutely, it can be as inappropriate as paternalism, as erring wholly in towards one or the other can oversimplify a moral situation. A dynamic balance between paternalism and autonomy dependant on the needs of the individual seems to be the most logical solution and in the authors’ experience, this does happen in practice, with good effect. 2710 words References. Mason JK & McCall Smith A (1998) Law and Medical Ethics. Edinburgh, Butterworths. Ascension health (2005) www.ascensionhealth.org/ethics/public/issues/autonomy.asp accessed on 31/1/06 at 1300. Beauchamp TL & Childress JF (1994) Principles of Biomedical Ethics. Oxford, Oxford University Press. Boyd KM, Higgs R & Pinching AJ, (1997) the New Dictionary of Medical Ethics. London, BMJ. British Medical Association (1993) Medical Ethics Today. London, BMJ. Clarke, P & Jones, J. (1998) Brigden’s Operating Department Practice. London, Churchill Livingstone. Davey, A & Ince, CS. (2000) Fundamentals of Operating Department Practice. London, Greenwich Medical Media. Department of Health (2001) Good practice in consent: Implementation Guide. London. DOH. Howard P & Bogle J (2005) Medical Law and Ethics. London, Blackwell. Konrad MS (1983) A Defence of Medical Paternalism. cited in Boyd KM, Higgs R & Pinching AJ, (1997) the New Dictionary of Medical Ethics. London, BMJ. Mallett, J & Bailey, C. (1996) Clinical Nursing Procedures. London, Blackwell Science. Mental Incapacity (1995) Law Commission Report 231. London, HMSO. Parker M & Dickenson D (2003) Medical Ethics Workbook. Cambridge, Cambridge University Press. Quill TE & Brody H (1996) Physician Recommendations and Patient Autonomy cited in Annals of Internal Medicine: 9: 763-769.