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Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Paternalism. Show all posts
Showing posts with label Paternalism. Show all posts

Thursday, January 25, 2024

Listen, explain, involve, and evaluate: why respecting autonomy benefits suicidal patients

Samuel J. Knapp (2024)
Ethics & Behavior, 34:1, 18-27
DOI: 10.1080/10508422.2022.2152338

Abstract

Out of a concern for keeping suicidal patients alive, some psychotherapists may use hard persuasion or coercion to keep them in treatment. However, more recent evidence-supported interventions have made respect for patient autonomy a cornerstone, showing that the effective interventions that promote the wellbeing of suicidal patients also prioritize respect for patient autonomy. This article details how psychotherapists can incorporate respect for patient autonomy in the effective treatment of suicidal patients by listening to them, explaining treatments to them, involving them in decisions, and inviting evaluations from them on the process and progress of their treatment. It also describes how processes that respect patient autonomy can supplement interventions that directly address some of the drivers of suicide.

Public Impact Statement

Treatments for suicidal patients have improved in recent years, in part, because they emphasize promoting patient autonomy. This article explains why respecting patient autonomy is important in the treatment of suicidal patients and how psychotherapists can integrate respect for patient autonomy in their treatments.


Dr. Knapp's article discusses the importance of respecting patient autonomy in the treatment of suicidal patients within the framework of principle-based ethics. It highlights the ethical principles of beneficence, nonmaleficence, justice, respecting patient autonomy, and professional-patient relationships. The article emphasizes the challenges psychotherapists face in balancing the promotion of patient well-being with the need to respect autonomy, especially when dealing with suicidal patients.

Fear and stress in treating suicidal patients may lead psychotherapists to prioritize more restrictive interventions, potentially disregarding the importance of patient autonomy. The article argues that actions minimizing respect for patient autonomy may reflect a paternalistic attitude, which is implementing interventions without patient consent for the sake of well-being.

The problems associated with paternalistic interventions are discussed, emphasizing the importance of patients' internal motivation to change. The article advocates for autonomy-focused interventions, such as cognitive behavior therapy and dialectical behavior therapy, which have been shown to reduce suicide risk and improve outcomes. It suggests that involving patients in treatment decisions, listening to their experiences, and validating their feelings contribute to more effective interventions.

The article provides recommendations on how psychotherapists can respect patient autonomy, including listening carefully to patients, explaining treatment processes, involving patients in decisions, and inviting them to evaluate their progress. The ongoing nature of the informed consent process is stressed, along with the benefits of incorporating patient feedback into treatment. The article concludes by acknowledging the need for a balance between beneficence and respect for patient autonomy, particularly in cases of imminent danger, where temporary prioritization of beneficence may be necessary.

In summary, the article underscores the significance of respecting patient autonomy in the treatment of suicidal patients and provides practical guidance for psychotherapists to achieve this while promoting patient well-being.

Tuesday, August 4, 2020

When a Patient Regrets Having Undergone a Carefully and Jointly Considered Treatment Plan, How Should Her Physician Respond?

L. V. Selby and others
AMA J Ethics. 2020;22(5):E352-357.
doi: 10.1001/amajethics.2020.352.

Abstract

Shared decision making is best utilized when a decision is preference sensitive. However, a consequence of choosing between one of several reasonable options is decisional regret: wishing a different decision had been made. In this vignette, a patient chooses mastectomy to avoid radiotherapy. However, postoperatively, she regrets the more disfiguring operation and wishes she had picked the other option: lumpectomy and radiation. Although the physician might view decisional regret as a failure of shared decision making, the physician should reflect on the process by which the decision was made. If the patient’s wishes and values were explored and the decision was made in keeping with those values, decisional regret should be viewed as a consequence of decision making, not necessarily as a failure of shared decision making.

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Commentary

This case vignette highlights decisional regret, which is one of the possible consequences of the patient decision-making process when there are multiple treatment options available. Although the process of shared decision making, which appears to have been carried out in this case, is utilized to help guide the patient and the physician to come to a mutually acceptable and optimal health care decision, it clearly does not always obviate the risk of a patient’s regretting that decision after treatment. Ironically, the patient might end up experiencing more regret after participating in a decision-making process in which more rather than fewer options are presented and in which the patient perceives the process as collaborative rather than paternalistic. For example, among men with prostate cancer, those with lower levels of decisional involvement had lower levels of decisional regret. We argue that decisional regret does not mean that shared decision making is not best practice, even though it can result in patients being reminded of their role in the decision and associated personal regret with that decision.

The info is here.

Sunday, March 29, 2020

Who gets the ventilator in the coronavirus pandemic?

A group of doctors pictured during a surgical operation, with a heart rate monitor in the foreground.Julian Savulescu & Dominic Wilkinson
abc.net.au
Updated on 17 March 20

Here is an excerpt:

4. Flatten the curve: the 'too little, too late' approach

There are two wishful-thinking approaches that try to make the problem go away.

The first is that we need more liberty to impose restrictions on the movement of citizens in an effort to "flatten the curve", reduce the number of coronavirus cases and pressure on hospitals, and allow everyone who needs a ventilator to get one.

That may have been possible early on (Singapore and Taiwan adopted severe liberty restriction and seemed to have controlled the epidemic).

However, that horse has bolted and it is now inevitable that there will be a shortage of life-saving medical supplies, as there is in Italy.

This approach is a case of too little, too late.

5. Paternalism: the 'greater harm' myth

The second wishful-thinking approach is that some people try to argue that it is harmful to ventilate older patients, or patients with a poorer prognosis.

One intensive care consultant wrote an open letter to older patients claiming that he and his colleagues would not discriminate against them:

"But we won't use the things that won't work. We won't use machines that can cause harm."

But all medical treatments can cause harm. It is simply incorrect that intensive care "would not work" in a patient with COVID-19 who is older than 60, or who has comorbidities.

Is a 1/1,000 chance of survival worth the discomfort of a month on a ventilator? That is a complex value judgement and people may reasonably differ. I would take the chance.

The claim that intensive care doctors will only withhold treatment that is harmful is either paternalistic or it is confused.

If the doctor claims that they will withhold ventilation when it is harmful, this is a paternalistic value judgement. Where a ventilator has some chance of saving a person's life, it is largely up to that person to decide whether it is a harm or a benefit to take that chance.

Instead, this statement is obscuring the necessary resource allocation decision. It is sanitising rationing by pretending that intensive care doctors are only doing what is best for every patient. That is simply false.

The info is here.

Thursday, July 25, 2019

Societal and ethical issues of digitization

Lambèr Royakkers, Jelte Timmer, Linda Kool, & Rinie van Est
Ethics and Information Technology (2018) 20:127–142

Abstract

In this paper we discuss the social and ethical issues that arise as a result of digitization based on six dominant technologies: Internet of Things, robotics, biometrics, persuasive technology, virtual & augmented reality, and digital platforms. We highlight the many developments in the digitizing society that appear to be at odds with six recurring themes revealing from our analysis of the scientific literature on the dominant technologies: privacy, autonomy, security, human dignity, justice, and balance of power. This study shows that the new wave of digitization is putting pressure on these public values. In order to effectively shape the digital society in a socially and ethically responsible way, stakeholders need to have a clear understand-ing of what such issues might be. Supervision has been developed the most in the areas of privacy and data protection. For other ethical issues concerning digitization such as discrimination, autonomy, human dignity and unequal balance of power, the supervision is not as well organized.

The paper is here.

Sunday, January 20, 2019

The Ethics of Paternalism

Ingrid M. Paulin, Jenna Clark, & Julie O'Brien
Scientific American
Originally published on December 21, 2018

Here is an excerpt:

Choosing what to do and which approach to take requires making a decision about paternalism, or influencing someone’s behavior for their own good. Every time someone designs policies, products or services, they make a decision about paternalism, whether they are aware of it or not. They will inevitably influence how people behave; there's no such thing as a neutral choice.

Arguments about paternalism have traditionally focused on the extreme ends of the spectrum; you either let people have complete autonomy, or you completely restrict undesirable behaviors. In reality, however, there are many options in between, and there are few guidelines about how one should navigate the complex moral landscape of influence to decide which approach is justified in a given situation.

Traditional economists may argue for more autonomy on the grounds that people will always behave in line with their own best interest. In their view, people have stable preferences and are always weighing the costs and benefits of every option before making decisions. Because they know their preferences better than do others, they should be able to act autonomously to maximize their own positive outcomes.

The info is here.

Saturday, November 17, 2018

The New Age of Patient Autonomy: Implications for the Patient-Physician Relationship

Madison Kilbride and Steven Joffe
JAMA. Published online October 15, 2018.

Here is an excerpt:

The New Age of Patient Autonomy

The abandonment of strong medical paternalism led scholars to explore alternative models of the patient-physician relationship that emphasize patient choice. Shared decision making gained traction in the 1980s and remains the preferred model for health care interactions. Broadly, shared decision making involves the physician and patient working together to make medical decisions that accord with the patient’s values and preferences. Ideally, for many decisions, the physician and patient engage in an informational volley—the physician provides information about the range of options, and the patient expresses his or her values and preferences. In some cases, the physician may need to help the patient identify or clarify his or her values and goals of care in light of the available treatment options.

Although there is general consensus that patients should participate in and ultimately make their own medical decisions whenever possible, most versions of shared decision making take for granted that the physician has access to knowledge, understanding, and medical resources that the patient lacks. As such, the shift from medical paternalism to patient autonomy did not wholly transform the physician’s role in the therapeutic relationship.

In recent years, however, widespread access to the internet and social media has reduced physicians’ dominion over medical information and, increasingly, over patients’ access to medical products and services. It is no longer the case that patients simply visit their physicians, describe their symptoms, and wait for the differential diagnosis. Today, some patients arrive at the physician’s office having thoroughly researched their symptoms and identified possible diagnoses. Indeed, some patients who have lived with rare diseases may even know more about their conditions than some of the physicians with whom they consult.

The info is here.

Wednesday, July 25, 2018

Heuristics and Public Policy: Decision Making Under Bounded Rationality

Sanjit Dhami, Ali al-Nowaihi, and Cass Sunstein
SSRN.com
Posted June 20, 2018

Abstract

How do human beings make decisions when, as the evidence indicates, the assumptions of the Bayesian rationality approach in economics do not hold? Do human beings optimize, or can they? Several decades of research have shown that people possess a toolkit of heuristics to make decisions under certainty, risk, subjective uncertainty, and true uncertainty (or Knightian uncertainty). We outline recent advances in knowledge about the use of heuristics and departures from Bayesian rationality, with particular emphasis on growing formalization of those departures, which add necessary precision. We also explore the relationship between bounded rationality and libertarian paternalism, or nudges, and show that some recent objections, founded on psychological work on the usefulness of certain heuristics, are based on serious misunderstandings.

The article can be downloaded here.

Monday, October 9, 2017

Would We Even Know Moral Bioenhancement If We Saw It?

Wiseman H.
Camb Q Healthc Ethics. 2017;26(3):398-410.

Abstract

The term "moral bioenhancement" conceals a diverse plurality encompassing much potential, some elements of which are desirable, some of which are disturbing, and some of which are simply bland. This article invites readers to take a better differentiated approach to discriminating between elements of the debate rather than talking of moral bioenhancement "per se," or coming to any global value judgments about the idea as an abstract whole (no such whole exists). Readers are then invited to consider the benefits and distortions that come from the usual dichotomies framing the various debates, concluding with an additional distinction for further clarifying this discourse qua explicit/implicit moral bioenhancement.

The article is here, behind a paywall.

Email the author directly for a personal copy.

Monday, October 17, 2016

Affective nudging

Eric Schliesser
Digressions and Impressions blog
Originally published September 30, 2016

Here is an excerpt:

Nudging is paternalist. But by making exit easy and avoidance cheap nudges are thought to avoid the worst moral and political problems of paternalism and (other) manipulative practices. (What counts as a significant change of economic incentives is, of course, very contestable, but we leave that aside here.) Nudges may, in fact, sometimes enhance autonomy and freedom, but the way Sunstein & Thaler define 'nudge' one may nudge also for immoral ends. Social engineering does not question the ends.

The modern administrative state is, however, not just a rule-following Weberian bureaucracy where the interaction between state and citizen is governed by the exchange of forms, information, and money. Many civil servants, including ones with very distinct expertise (physicians, psychologists, lawyers, engineers, social service workers, therapists, teachers, correction officers, etc.) enter quite intimately into the lives of lots of citizens. Increasingly (within the context of new public management), government professionals and hired consultants are given broad autonomy to meet certain targets (quotas, budget or volume numbers, etc.) within constrained parameters. (So, for example, a physician is not just a care provider, but also somebody who can control costs.) Bureaucratic management and the political class are agnostic about how the desired outcomes are met, as long as it is legal, efficient and does not generate bad media or adverse political push-back.

The blog post is here.

Friday, July 8, 2016

Could a device tell your brain to make healthy choices?

by Yasmin Anwar
Futurity
Originally posted June 13, 2016

New research suggests it’s possible to detect when our brain is making a decision and nudge it to make the healthier choice.

In recording moment-to-moment deliberations by macaque monkeys over which option is likely to yield the most fruit juice, scientists have captured the dynamics of decision-making down to millisecond changes in neurons in the brain’s orbitofrontal cortex.

The article is here.

Friday, June 3, 2016

Disclosure of incidental constituents of psychotherapy as a moral obligation for psychiatrists and psychotherapists

Manuel Trachsel & Jens Gaab
J Med Ethics 2016;0:1–3.
doi:10.1136/medethics-2015-102986

Abstract

Informed consent to medical intervention reflects the moral principle of respect for autonomy and the patient's right to self-determination. In psychotherapy, this includes a requirement to inform the patient about those components of treatment purported to cause the therapeutic effect. This information must encompass positive expectancies of change and placebo-related or incidental constituent therapy effects, which are as important as specific intervention techniques for the efficacy of psychotherapy. There is a risk that informing the patient about possible incidental constituents of therapy may reduce or even completely impede these effects, with negative consequences for overall outcome. However, withholding information about incidental constituents of psychotherapy would effectively represent a paternalistic action at the expense of patient autonomy; whether such paternalism might in certain circumstances be justified forms part of the present discussion.

The article is here.

Sunday, January 17, 2016

Should we Prohibit Breast Implants?

Collective Moral Obligations in the Context of Harmful and Discriminatory Social Norms

By Jessica Laimann
Journal of Practical Ethics
Volume 3 Issue 2. December 2015

ABSTRACT

In liberal moral theory, interfering with someone’s deliberate engagement in a self-harming practice in order to promote their own good is often considered wrongfully paternalistic. But what if self-harming decisions are the product of an oppressive social context that imposes harmful norms on certain individuals, such as, arguably, in the case of cosmetic breast surgery? Clare Chambers suggests that such scenarios can mandate state interference in the form of prohibition. I argue that, unlike conventional measures, Chambers’ proposal recognises that harmful, discriminatory norms entail a twofold collective moral obligation: to eliminate the harmful norm in the long run, but also to address unjust harm that is inflicted in the meantime. I show that these two obligations tend to pull in opposite directions, thus generating a serious tension in Chambers’ proposal which eventually leads to an undue compromising of the second obligation in favour of the first. Based on this discussion, I develop an alternative proposal which, instead of prohibiting breast implant surgery, offers compensation for the disadvantages suffered by individuals who decide not to have surgery.

The paper is here.

Monday, December 14, 2015

Professional Intuition Is Under Assault, Wachter Says

By Marcia Frellick
Medscape.com
Originally published November 24, 2015

Profession intuition — the gut feeling doctors get with experience and instinct that something just isn't right — is under assault, Robert Wachter, MD, professor of clinical medicine at the University of California, San Francisco, told the audience at TEDMED 2015.

"It's suspicious, it's soft, it's squishy," said Dr Wachter, the physician who, along with Lee Goldman, MD, coined the word "hospitalist" in 1996 (N Engl J Med. 1996;335:514-517).

"There's not an algorithm for it, it's not evidence-based," he explained. And "it's antidemocratic, it's paternalistic."

The entire article is here.

Thursday, October 16, 2014

It’s All for Your Own Good

By Jeremy Waldron
The New York Book Review
Originally published on October 9, 2014

Here is an excerpt:

Nudging is an attractive strategy. People are faced with choices all the time, from products to pensions, from vacations to voting, from requests for charity to ordering meals in a restaurant, and many of these choices have to be made quickly or life would be overwhelming. For most cases the sensible thing is not to agonize but to use a rule of thumb—a heuristic is the technical term—to make the decision quickly. “If it ain’t broke don’t fix it,” “Choose a round number,” “Always order the special,” and “Vote the party line” are all heuristics. But the ones people use are good for some decisions and not others, and they have evolved over a series of past situations that may or may not resemble the important choices people currently face.

The entire article is here.