Moral Theory and Neurology

Consent issues in neurology

The requirement that doctors obtain valid consent from patients before providing medical treatment has long been ingrained in both legal doctrine and medical ethics. We summarize the foundations of the informed consent doctrine and discuss the recent evolution in thinking about consent and medical decision making. We show how consent has evolved from physicians merely providing patients information to shared decision making between patients and physicians. We then address three specific examples of situations common in neurological practice that pose challenges in obtaining valid consent: the administration of intravenous tPA following ischemic stroke, consideration of carotid endarterectomy for carotid artery stenosis, and implementation of do-not-resuscitate orders.

Ethical and legal issues in palliative care

This article reviews the ethical principles underlying palliative care, stressing the importance of respecting patient's rights to withdraw or withhold life-sustaining treatment, including artificial hydration and nutrition. There is no ethical or constitutional right to receive physician-assisted suicide or voluntary active euthanasia. This article discusses current ethical controversies in palliative care, including futility, medication dosage and double-effect, terminal sedation, legalization of physician-assisted suicide and euthanasia, and patient refusal of hydration and nutrition. Relevant legal issues are discussed in tandem with the ethical issues.

Informed consent

Physicians have an ethical and legal duty to obtain patients' informed consent before ordering testing and treatment. Informed consent encompasses informed refusal, the correlative right of patients to refuse tests and therapies they do not want. A patient's informed consent requires adequate information, capacity to decide, and absence of coercion. Informed consent is incorporated into a process of agreement between a patient and a physician called "shared decision making." The procedural requirements of informed consent vary as a function of the risks of the tests or treatments. Incompetent patients require surrogate decision makers to consent or refuse on their behalf. Older children and adolescents should be asked to provide their assent for treatment in addition to their parents' permission. Treatment may be provided in an emergency situation without consent if the treatment given represents the standard of emergency care. Consent of human subjects for participation in research requires that they fully understand their role and risks, not be coerced, and be allowed to withdraw at any time without penalty. Institutional review boards help guarantee the protection of human subjects. Vulnerable research subjects, such as children and the cognitively or mentally impaired, require additional protection.

Physician experience as a measure of competency: implications for informed consent

The following description is based upon an actual case in which a patient initiated legal action after suffering a complication subsequent to an invasive diagnostic procedure performed by a senior fellow. Named as codefendants were the senior fellow, attending physician, and the hospital. Because any hospital with house staff is potentially vulnerable to similar litigation, Ethics Committees at Work is addressing the questions raised by this dilemma.