LOVIE JAPHET S.

LOPEZ, RN

The practice of medicine is a moral enterprise involving values that may conflict. Autonomy,
beneficence / nonmaleficence, justice, veracity and fidelity are well defined and supported ethical values in
medicine.

It is important to consider these values both from the patient’s / family’s perspective and the
healthcare professional’s perspective. The ongoing relationship between the healthcare professional and the
patient / family forms the foundation on which decisions are made.

A. AUTONOMY
 Autonomy is Latin for "self-rule".
 We have an obligation to respect the autonomy of other persons, which is to respect the decisions
made by other people concerning their own lives.
 This is also called the principle of human dignity.
 It gives us a negative duty not to interfere with the decisions of competent adults, and a positive
duty to empower others for whom we’re responsible.
 Example: A pregnant woman is in a unique position in that she is/represents, in effect, two patients,
herself and her fetus (or her children in the case of a multiple pregnancy). An autonomous informed
decision made by a pregnant woman will affect both patients. Autonomy also refers to the self-
governance of the healthcare professional, in so far as the healthcare professional comes to the
relationship with a set of moral standards by which to live.

What the law says

An adult patient who…suffers from no mental incapacity has an absolute right to choose whether
to consent to medical treatment… This right of choice is not limited to decisions which others might
regard as sensible. It exists notwithstanding that the reasons for making the choice are rational, irrational,
unknown or even non-existent.

(Lord Donaldson. Re T (Adult) [1992] 4 All ER 649.)

Two Conditions for Autonomy

Two conditions are ordinarily required before a decision can be regarded as autonomous.

1. The individual has to have the relevant internal capacities for self-government.
2. Has to be free from external constraints.

In a medical context a decision is ordinarily regarded as autonomous where the individual has the
capacity to make the relevant decision, has sufficient information to make the decision and does so
voluntarily.
Decisions where Autonomy is lacking

Given that there is a strong obligation to respect the decisions of autonomous adults – in relation
to medical treatment the only possible exception is the provision of compulsory treatment under mental
health legislation – how should we proceed when the conditions for autonomous decision-making are not
met?

Much will depend on the reasons why the conditions are lacking. If someone is being coerced into
making a decision, then it cannot be said to be theirs and should not be respected. In reality coercion is not
always easy to detect. A young woman who visits a GP with her partner for a termination of pregnancy
may for example be under pressure to proceed. If a doctor had concerns about coercion, good practice
would involve spending some time alone with the patient in order to confirm that the decision is genuinely
hers.

Food for thought

 Where patients lack the capacity to make a decision it follows necessarily that decisions must be
made on their behalf.
 Very young children ordinarily have the majority of decisions made by parents and carers.
 Where adults lack capacity health care decisions are ordinarily made by the health professional in
overall charge of their care although adults can appoint someone to make decisions on their behalf.
 In practice, decisions relating to incapacitated adults are closely regulated by law.

What’s the moral problem?

Should someone suffering from severe anorexia be forcibly fed? We have seen that a competent
adult can refuse medical treatment even if it will result in her death. Why then should an adult woman of
ordinary intelligence not have a decision to refuse food respected? The justification is usually that the
anorexia has undermined her ability to make an autonomous decision. The decision to refuse food, it is said,
is not authentically hers, rather it springs from the mental disorder that has her in its grip. Force feeding
could be described as a paternalistic intervention designed to facilitate further treatment with the intention
of resurrecting her ability to make authentically autonomous decisions.
B. VERACITY
 Or truth telling, is the hallmark of a fiduciary relationship.
 In order to provide quality healthcare, the healthcare professional requires accurate information
pertinent to the problem from the patient or family. In addition, the patient or family needs accurate
information about the diagnosis, prognosis, and treatment options to make an informed decision.
 While this principle is not a law, violation of ethical principles, including veracity, will result
in a loss of credibility and respect with other professionals and patients alike. Because medical
personnel hold a position of trust in the community, they are held to high standards which
promote accountability and overall professionalism.

Informed Consent

 The first application of the principle of veracity relates to informed consent and the autonomy
of the patient to make decisions based on all available information.
 Patients need to know the truth about their medical situation and their options. However, some
patients or their families may not want the full truth disclosed to them.
 An example may be if a patient is suspected to be seriously ill but is in the office for a visit on
December 17. Due to the proximity of the Christmas holiday, medical personnel may simply
request a follow-up visit immediately after Christmas, instead of relating all the ramifications
of the illness at the initial appointment. Family dynamics are an additional consideration as
well.

Professional Ethics

Veracity in conjunction with professional ethics relates to integrity in overall standards such as
billing, documentation, certification, health standards, overall compliance and peer relationships. These
do not address the medical professional's personal interaction with the patient but rather address general
behavior in areas which impact the patient indirectly.

Violations of Veracity

Veracity can be violated in several ways. Omission means that critical relevant facts are
intentionally left out when disclosing the patient's medical information. Commission means that medical
personnel intentionally tell the patient, or her family, a lie. A third, more subtle way to violate the
principle of veracity is to cloak the truth in so much medical jargon that the patient or her family will
be unable to understand it.