Market liberalism in health care: a dysfunctional view of respecting "consumer" autonomy

Current models of shared decision-making are insufficient: The "Professionally-Driven Zone of Patient or Surrogate Discretion" offers a defensible way forward

OBJECTIVES

This paper undertakes a critical examination of the concept of "Shared Decision-Making" (SDM) by exploring current understandings of what is meant by the term.

DISCUSSION

In an exploration of SDM, it will become evident that there are significant challenges that can limit shared decision-making's successful implementation in practice. Existing models are examined, and a novel method of SDM is proposed which makes use of a Professionally-Driven Zone of Patient or Surrogate Discretion.

CONCLUSION

A Professionally-Driven Zone of Patient or Surrogate Discretion is a broadly-applicable model of SDM that takes a harm-threshold approach, rather than appealing strictly to best interests. This model avoids or addresses many of the challenges that impede successful implementation of other SDM models.

PRACTICE IMPLICATIONS

The Professionally-Driven Zone of Patient or Surrogate Discretion aims to define the scope of participant roles in SDM better than existing models, and ensures that the treatments or interventions which are pursued in SDM are chosen from a range of ethically-defensible options.

Is shared decision-making to blame for the provision of ethically inappropriate treatment? Results of a multi-site study exploring physician understanding of the "shared" model of decision making

Support for the concept of respect for first-person informed consent and patient autonomy, including the negative right of patients to refuse unwanted interventions has grown, but does not generally include a positive right of patients to receive whatever treatment they request or demand without constraint. Despite this, health-care providers in both Canada and the United States are guilty of providing, in their own opinions, futile or probably futile treatments at the request of patients or their substitute decision-makers. The purpose of this study was to examine whether physicians' understanding of the shared model of medical decision-making - shared decision-making, (SDM) - may be among the reasons why some patients receive treatment understood as ethically inappropriate, including those deemed futile, treatments that are not medically indicated, or those that are not in the patient's best interests to receive. A secondary question asked to study participants was whether they believed their professional college allowed, or further, required them to use shared decision-making in their practice. The initial hypothesis of the researcher in this study was that SDM is not well understood by physicians, and that this lack of understanding, combined with other factors to be discussed in the full text, may result in patients receiving ethically-inappropriate treatment. Results suggest support for this hypothesis, and that SDM should be more closely examined if it is to be pursued as a method of decision making.

Patient-Centered Care and Autonomy: Shared Decision-Making in Practice and a Suggestion for Practical Application in the Critically Ill

Decision-making for the hospitalized dying and critically ill is often characterized by an understanding of autonomy that leads to clinical care and outcomes that are antithetical to patients' preferences around suffering and quality of life. A better understanding of autonomy will facilitate the ultimate goal of a patient-centered approach and ensure compassionate, high-quality care that respects our patients' values. We reviewed the medical literature and our experiences through the ethics service, palliative care service, and critical care service of a large community teaching hospital. The cumulative experience of a senior intensivist was filtered through the lens of a medical ethicist and the palliative care team. The practical application of patient-centered care was discerned from these interactions. We determined that a clearer understanding of patient-centeredness would improve the experience and outcomes of care for our patients as well as our adherence to ethical practice. The practical applications of autonomy and patient-centered care were evaluated by the authors through clinical interactions on the wards to ascertain problems in understanding their meaning. Clarification of autonomy and patient-centeredness is provided using specific examples to enhance understanding and application of these principles in patient-centered care.

Patients' sense of responsibility to healthcare providers and its predictors: A national cross-sectional survey in China

Objectives

To evaluate patients’ sense of responsibility to healthcare providers and to determine its predictors using on a national sample in China.

Methods

We conducted a national cross-sectional survey in China with a stratified cluster sample of patients treated in 77 hospitals between July 2014 and April 2015. Patients’ sense of responsibility to healthcare providers was measured with four questions assessing patients’ perceptions regarding their responsibilities to respect doctors, respect nurses, coordinate with health professionals, and comply with hospital rules. Predictors included patient sociodemographic characteristics and their past hospitalization experience.

Results

Small proportions of respondents reported that they perceived having no responsibility to respect doctors (8.9%), respect nurses (7.9%), comply with hospital rules (6.7%), or coordinate with health professionals (6.3%). Multivariate regression analyses showed that the strongest predictor of patients’ sense of responsibility to healthcare providers was patinets’ trust in health professionals, followed by patients’ education level. Familiarity with healthcare professionals and past hospitalization frequency were inversely associated with patients’ sense of responsibility to healthcare providers.

Conclusions

Although only a small proportion of the patients reported feeling no or low sense of responsibility to healthcare providers, the lack of respect and collaboration from these patients can negatively affect patient-provider relationships. Healthcare administrators need to communicate clearly with the patients and the public about the role of patients and the limitations of medicine in order to instill a sense of patients’ responsibility.

Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate

It has been proposed that medical organizations adopt neutrality with respect to physician-assisted suicide (PAS), given that the practice is legal in some jurisdictions and that membership is divided. We review developments in end-of-life care and the role of medical organizations with respect to the legalization of PAS since the 1990s. We argue that moving from opposition to neutrality is not ethically neutral, but a substantive shift from prohibited to optional. We argue that medical organizations already oppose many practices that are legal in many jurisdictions, and that unanimity among membership has not been required for any other clinical or ethical policy positions. Moreover, on an issue so central to the meaning of medical professionalism, it seems important for organized medicine to take a stand. We subsequently review the arguments in favor of PAS (arguments from autonomy and mercy, and against the distinction between killing and allowing to die (K/ATD)) and the arguments against legalization (the limits of autonomy, effects on the patient-physician relationship, the meaning of healing, the validity of the K/ATD distinction, the social nature of suicide, the availability of alternatives, the propensity for incremental extension, and the meaning of control). We conclude that organized medicine should continue its opposition to PAS.