Medical Ethics for the Boards PDF

 5 Chapter 2: Competence and the Capacity to Make Decisions...

 5 Chapter 2: Competence and the Capacity to Make Decisions DEFINITIONS Competence is a legal term. Competency decisions transpire within the judicial system. Only a court can determine that a patient is incompetent. All adult patients are considered competent unless specifically proven otherwise. Physicians can determine whether or not a patient has the capacity to understand his medical condition. The physician makes a determination of the capacity of a patient to comprehend her medi- cal problems based on whether there is an organic delirium due to a medical condition such as a sodium problem, hypoxia, drug intoxication, meningitis, encephalitis, or a psy- chiatric disorder. These determinations are based in large part on a neurological examina- tion testing memory, comprehension, reasoning, and judgment. Any physician can make this determination. The physician does not have to be a psychiatrist. A psychiatrist may be useful in rendering decision-making capacity determinations in cases that are complex or equivocal. If the patient obviously does or does not have the capacity to understand, a psychiatrist is not needed. MINORS By definition, a minor is a person under the age of 18. With some exceptions, minors are generally not considered competent to make their own decisions. Only a parent or a legal guardian can give consent for a minor. Neighbors, aunts, uncles, and grandparents cannot give consent for treatment of a minor. This rule does not cover life-threatening or serious emergencies. Consent is always implied for emergency treatment. A physician should not withhold blood or surgery in a life-threatening accident just because the parent is not present. 01 USMLE Ethics txt New.indd 5 13/11/15 1:06 pm  6 Medical Ethics for the Boards For example, a 10-year-old boy accidentally runs through a glass window at school and lacerates the radial artery. His teacher brings him to the emergency department. The boy is bleeding and needs both a blood transfusion and surgery to correct the defect. What should you do? Emergency treatment of a minor does not need express written consent. Parental consent is implied. Saying that you had to ask another person such as the teacher, the principal, the school nurse, the babysitter, or the grandparents for consent before giving emergency treatment would be the wrong answer. Seeking a court order is also a wrong choice in an emergency because it delays the treatment and because in an emergency it is implied that the parents would consent if they were there. Partial Emancipation Although only a parent or guardian can give consent for procedures and therapies for a minor there are some exceptions to this rule in the areas of prenatal care, contraception, sexually transmitted diseases (STDs), and substance abuse. The mature minor is generally one above the age of 15, although this varies by state. USMLE will not make hairsplitting distinctions like giving you a 14-year-old the day before her 15th birthday. The case on the exam will be clear. For example, a 16-year-old girl comes to see you in clinic to discuss contraception. She is generally healthy but is not accompanied by a parent. What should you do? In all cases like this involving prenatal care, STDs, contraception, HIV and substance abuse the answer should be to treat the patient. Saying that you must notify the parents, get a court order, seek legal counsel, refuse therapy, or to go to the ethics committee are all incorrect answers. These interventions are not necessary. Society has an interest in preventing unwanted pregnancy, so it is considered less harmful to treat without parental notification than it is to take the risk that a teenager will get pregnant and need an abortion later. Abortion in a Minor The rules on parental notification for abortion are less clear because there is no national standard. Some states require parental notification and some don’t. 01 USMLE Ethics txt New.indd 6 13/11/15 1:06 pm  Chapter 2: Competence and the Capacity to Make Decisions 7 For example, a 16-year-old girl comes to see you in her first trimester of preg- nancy. She is seeking an abortion. What should you do? In this case, there is no clear answer about whether or not the physician should notify the parents. There is no clear national standard and it depends upon the state you are in. The most likely right answer will indicate the need to encourage the child to notify the parents herself, which would be best. So the correct answer choice will say some- thing like “encourage discussion,” “counsel her to tell the parents herself,” or “suggest a family meeting.” On the ethics questions for USMLE, if there is a choice that says to discuss, confer, meet, or have voluntary notification, this will generally be the right thing to do first. Emancipated Minor A small number of minors, particularly at older ages such as 16 or 17, may be considered “emancipated” or freed of the need to have parental consent for any medical care. The cri- teria are that the minor is married, self-supporting and living independently, in the military, or the parent of a child that they themselves support. The criteria for being an emancipated minor relate to being no longer dependent on one’s parents for support. In other words, if the minor does not live with his parents, has a job, and is self-supporting financially, then the minor no longer is dependent upon parental consent for his actions. An emancipated minor is free to make health-care decisions in all areas, not only just STDs, prenatal care, contraception, or substance abuse. Serious medical conditions or procedures such as organ donation, surgery, or abortion may require a specific court order to allow the legal standing of emancipation to be fully valid. Only answer “court order,” “judicial intervention,” “court trial,” or “seek legal resolution” if the case represents dis- agreement or a lack of consensus in the stem. Limitations on Parental Right of Refusal for Minors Although a competent adult can refuse any medical care she wishes, the same right does not automatically extend for parents concerning their children. Parents cannot refuse life- saving treatment for their child based on religious belief. The state has an interest in the welfare of the child that exceeds the parental right to deny therapy for the child if the child might die. 01 USMLE Ethics txt New.indd 7 13/11/15 1:06 pm  8 Medical Ethics for the Boards For example, a child is in a motor vehicle accident and sustains head trauma requiring surgery to drain a hematoma that, if left untreated, will be fatal. As part of the surgery the child will need a blood transfusion. The parents are Jehovah’s Witnesses and refuse to give consent for the transfusion. The parents’ stated reli- gious beliefs are that accepting blood for their child would be a fate worse than death. What should you do? If the child needs blood to save his life you must give the blood—even over the objection of the parents. It may seem contradictory to seek parental consent for a procedure that you will perform even if they refuse, but in this case, you should attempt to obtain their permission nonetheless. Withholding lifesaving therapy for a child is considered comparable to child abuse. The parents’ right to practice their religion in terms of health care would cover their ability to refuse a transfusion for themselves, but not for their child. This ethical concept has only expanded. Parents cannot refuse therapy for children even if they are severely brain damaged or otherwise developmentally disabled. Society does not distinguish between individuals based on their relative ‘worth.’ In other words, parents cannot refuse tracheo-esophageal fistula repair on a patient with Down syndrome just because the mental capacity and functional ability of the child will be much less than that of a child without this disease. From this point of view, treatment against parents’ wishes in a life-threatening situation is equally valid for both a future genius and a child with cerebral palsy who will not achieve a mental age above 2. One of the only times parents are allowed to refuse care for their child is when the child is so ill or deformed that death is inevitable. This is not a true refusal on the part of the parent. This is really just saying that parents can refuse only the futile care that the doctor shouldn’t be giving anyway. PSYCHIATRIC PATIENTS A patient’s psychiatric history is intrinsic to the concept of competence and to the patient’s capacity to understand her medical problems. A patient with the clear capacity to under stand or one who clearly does not have capacity does not need a psychiatric evaluation. However, a psychiatric evaluation can be useful to help make a determination of capacity in equivocal or questionable cases. 01 USMLE Ethics txt New.indd 8 13/11/15 1:06 pm  Chapter 2: Competence and the Capacity to Make Decisions 9 All suicidal patients are considered to lack capacity to understand because active suicidal ideation is deemed to be a sign of impaired judgment. In addition, the level of competence necessary to make financial decisions is different from that necessary for an informed refusal. In other words, a patient may have a history of bipolar disorder making it impos- sible for him to manage his financial decisions. However, the same person might still be considered to have capacity to refuse treatment. There is a very limited demand placed on patients to establish capacity to refuse treatments. CAPACITY TO REFUSE PROCEDURES IN AN OTHERWISE MENTALLY DISABLED PATIENT A patient with mental illness or mental retardation that might be considered incompetent for other areas of life may still retain the right to refuse medical procedures. The criteria to determine competence in areas of finance are at a higher standard than those for refus- ing medical procedures. Your patient might have schizophrenia, mental retardation, or autism to the point of needing to live in a group home, but that does not mean they are incapable of understanding medical procedures. This means that an adult with a mental age of 8 or 10 may still be allowed to refuse medical procedures. Our society is reluctant to strap a patient to his bed and perform procedures that would be painful or uncomfort- able for the patient without his consent. For instance, certain court cases in the past have allowed a patient with mental illness to refuse diagnostic procedures even though two out of three of the reasons for the refusal were delusional. This is an affirmation of how deep the principle of autonomy goes in the management of patients. In addition, it shows that beneficence—trying to do the right thing for patients—is considered less important than autonomy. Autonomy is given more weight in decision making than beneficience. Autonomy has priority. A person may meet the legal standard of competence to refuse or accept medical care even if she is not considered competent in other areas of life, such as financial matters. 01 USMLE Ethics txt New.indd 9 13/11/15 1:06 pm