When consent is unbearable--a case report.

Abstract

Informed consent has become one of the central problems in medical ehtics. At first sight, it would seem that no argument can be made against a person's right to be fully aware of the extent, course, and implications of his medical condition. It seems equally obvious that it is the patient's right to participate in, influence, or fully and solely assume the decisions of medical actions that should be undertaken or withheld with regard to his disease. Nevertheless, there are circumstances in which these commonly held assumptions about a patient's rights may not apply. It is the purpose of this report to describe a case where informed consent was deliverately not sought, and to discuss the ethical issues involved.

Consent in terminal sedation

“…Such a paternalistic stance may be considered a cause for conflict between the medical team and proxies, but this is rare, and even where such conflicts do occur, 79% of cases arrive at amicable settlements (25,26). Furthermore I hold that in a terminally ill patient with intractable symptoms, where there is a conflict between the patient's well being and his self-determination, the former should trump the latter (24,27). The reason is that patients making these decisions may not be competent or fully aware of the repercussions of such decisions, which is not surprising.…”

“…Given that only 13% of family members are aware of a patient's treatment preferences, the medical profession has a legal and social duty to protect the rights and opportunities of the vulnerable (22,23). Furthermore, given the scarcity of AMDs and the well-documented fallibility of proxies and surrogates in making end of life decisions, the patient's best interest should be determined by the physician in charge, who should be guided, whenever possible, by the advice of proxies and surrogates (24). Indeed, even when the courts give proxies and surrogates decision making authority, I argue that physicians ought to continue to ensure that any decision taken is in the patient's best interest -this is part of their duty of nonabandonment.…”

Best interests determination within the Singapore context

“…[114][115][116][117] Such analysis would clearly benefit from a multidisciplinary team approach where this determination must necessarily consider matters both clinical and nonclinical and to a depth and range required to best mirror the patient's specific circumstances, views, values and wishes. [109][110][111][112][113][118][119][120][121][122][123][124][125][126][127][128][129] Indeed, in order to carry out such complex balancing of various considerations, weight or value to each of these facets should then be assigned based upon the specific context of the patient's situation and a benefitdisbenefit analysis carried out for each option proffered. Here each option is reviewed upon objective, rational, complementary and dispassionate analysis to ascertain, which treatment modality will produce the greatest benefit that can realistically be provided to the patient.…”

“…Such a conclusion guided in part by Krishna and Chin's ideal of the Duty of Palliative Care is then deemed to be the option that represents the best means of realizing, protecting or advancing a patient's best interest. [8][9][10][117][118][119][120][121][122][123][124][125][126][127][128] This determination needs to take a nuanced view of the situation within the particular context of the patient's condition to determine the value ascribed to each of these facets. In turn, it assuages linking the determination of value or weight to a thorough and holistic assessment of the patient within their specific context while maintaining a 'minimum threshold of acceptable care' that ideally ought to be determined by the patient in concert with their family, carers and health-care professionals.…”