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Free Choice and Patient Best Interests

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Abstract

In medical practice, the doctrine of informed consent is generally understood to have priority over the medical practitioner’s duty of care to her patient. A common consequentialist argument for the prioritisation of informed consent above the duty of care involves the claim that respect for a patient’s free choice is the best way of protecting that patient’s best interests; since the patient has a special expertise over her values and preferences regarding non-medical goods she is ideally placed to make a decision that will protect her interests. In this paper I argue against two consequentialist justifications for a blanket prioritisation of informed consent over the duty of care by considering cases in which patients have imperfect access to their overall best interests. Furthermore, I argue that there are cases where the mere presentation of choice under the doctrine of informed consent is detrimental to patient best interests. I end the paper by considering more nuanced approaches to resolving the conflict between informed consent and the duty of care and consider the option of permitting patients to waive informed consent.

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Notes

  1. These two consequentialist arguments for the prioritisation of informed consent are by no means exhaustive. A third consequentialist argument for the prioritisation of informed consent, for instance, emphasises the importance of informed consent procedures for facilitating patient trust [19, 28]. Informed consent procedures have been argued to be instrumental to promoting the patient’s trust in medical institutions and practitioners because only those who ‘understand what is proposed and who are in a position to refuse or choose in light of that understanding’ (as required by the doctrine of informed consent) are able to give their trust [40: 18]. The challenges to trust-promotion arguments for informed consent are explored in great detail in Eyal [19]. The unique focus of this paper will be on the arguments from epistemic privilege (“The Argument from Epistemic Privilege” section) and the argument from therapeutic benefit (“The Argument from Therapeutic Benefit” section). I would, however, like to thank [BLINDED] for indicating this third possibility.

  2. See also, O’Neill [40: 32].

  3. For instance, it is widely claimed that: “…the exercise of patient autonomy is contingent on the ability to understand relevant information and on the receipt of such information” [25: 417–418], and that: “The only way physicians in the future will be able to approximate knowledge of what serves their patients’ interests is to ask them…the patients themselves are likely to be the most reliable source physicians have of knowing their patients’ interests” [59: 707]. For instance, the Nuremberg code requires that the potential research subject: “…should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be made known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person which may possibly come from his participation in the experiment” [38]. Likewise, the department of health states that: “The provision of information is central to the consent process. Before patients can come to a decision about treatment, they need comprehensible information about their condition and about possible treatments/investigations and their risks and benefits (including the risks/benefits of doing nothing)” [15: 17]. It is thus argued that fully informed consent requires that: “… a person must have all the [medical] information required to form a final decision” [57: 1.3].

  4. For a comprehensive overview see Thaler and Sunstein [56] and White [61].

  5. For example, see Slovic [50, 51]. For a dispute of these findings see Wright et al. [64: 1118].

  6. For a comprehensive overview of this debate, see: Ost [41], Harris and Keywood [25], Malpas [34], Rhodes [42]; See Bortolotti [7] for a response.

  7. The dialectic of this paper would thereby reflect the more general collapse of rule consequentialism into act utilitarianism as presented by Smart [52].

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Acknowledgments

I would like to thank the anonymous reviewers and a number of friends and colleagues for their comments on earlier drafts. In particular, Philip Goff, Heather Widdows and Iain Law. I would also like to thank the attendees of the Royal Institute of Philosophy seminar at Queen's University Belfast, and the 5th Interdisciplinary Workshop in the Philosophy of Medicine: Medical Knowledge, Medical Duties at King's College London for their invaluable input.

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  1. Department of Philosophy, Central European University, Zrinyi u. 14., 4th Floor, Budapest, 1051, Hungary

    Emma C. Bullock

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Bullock, E.C. Free Choice and Patient Best Interests. Health Care Anal 24, 374–392 (2016). https://doi.org/10.1007/s10728-014-0281-8

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