Many patients need help obtaining the necessary information, mediate with physicians and ethics committees and getting second opinions from independent physicians to make decisions on their care. This is especially important in the hospital when receiving complete and timely information is critical. The fundamental basis for making those decisions is understandable medical information that not only includes diagnosis and prognosis but also a realistic picture of quality of life under various circumstances. Questions of the capacity of the patient to make decisions and differences of personal, cultural and religious perspective on continuing or withholding life sustaining treatment occur. A bioethics consultant can help bridge this gap.

Physicians are often reluctant to broach the subject, or not very good at discussing these issues, or both. Implicit bias by medical care providers may affect the degree and clarity of the information provided.

Such discussions should not be limited to meeting on one occasion. There should be an ongoing discussion especially with patients who are facing serious illness.

Confusion, lack of information and lack of understanding leads to fear. For patients to be empowered they must understand levels of risk, upside and downside, and know that they and their decision makers are entitled to all necessary information and participation in their treatment decisions. The ability to decide for oneself is all we have and that should not be taken from us at a time of illness.

Levels of capacity vary over time. A person may be incompetent due to levels of sedation or the effects of sepsis on cognitive function. A person who signs an advance health directive five years earlier does not mean that we should not ask them, if competent, what they want to do in a specific situation now. An Advanced Health Directive is one that is made in anticipation of a time when decisions cannot be made. This, however, does not militate against a person making a medical decision at anytime when they are able to do so. A patient’s understanding and ability to reason with respect to medical decisions may in fact increase overtime as the patient’s comprehension and experience of their medical condition improves.

Patient and decision makers must be able to understand, deliberate, and communicate their choices. There are also the issues of degree of disclosure as well as avoidance of implicit bias and undue influence.

It is the job of the clinical bioethicist to oversee this ongoing process and application of consistent standards that need to be respected. These standards and their applications must be guided by principles of respect for person and distributive justice. There are decisions, which must be made, but nevertheless must be governed by ethical requirements and legal duties and obligations.

A physician is legally required to explain, in understandable terms to each individual patient or decision maker, the diagnosis, prognosis of a patient, as well as the risks of alternative types of treatments or not treating. This is an ongoing process. Just as there need to be continuity of care, there must be continuity of providing timely information. Timely means at a time, when possible, a thoughtful consideration of the information and time for reasonable questions. If there is insufficient timely information there can be no legitimate consent.

Clinical bioethics recognizes that in medical treatment it is the duty of the physician to gain consent through full disclosure such that what is being consented to is reasonably identical to risks and benefits of the contemplated care. It is critical to keep in mind that the greater the risk, the greater the duty is to ensure an intelligent grasp of the risks and benefits from a patient. John Stuart Mill in his work “On Liberty,” would have described these duties as requiring: “…free, voluntary and undeceived consent and participation…”

For physicians the role of bioethics, in this regard, is to educate, ensure, verify, and to fully and transparently document the legitimate fulfillment of these duties.

For more information, visit: https://bernardfreedman.com/

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