Tag: patient autonomy

Blog Posts (6)

November 30, 2016

Handing over the Control in Breast Reconstruction Surgery


A company named AirXpanders is in the process of developing a medical device that will give women a
sense of control over breast reconstruction surgery.  The name of the product is AeroForm and it is currently under review by the FDA.  It is approved in Europe and sold in Australia. AeroForm is currently in clinical trials.

Using an implant is the current standard of care for breast reconstruction.
  In order for an implant to achieve its designed purpose, space must be made in the breast tissue.  Before AeroForm, this space was achieved through multiple visits to the doctor’s office using a saline injection. It was a painful process for some women and could take months. AeroForm is a wireless, needle-free tissue expansion device.  A device is surgically inserted into the breast that will deliver small amounts of CO2 gas to expand the tissue as the saline used to do. The release of the gas is controlled through an internal valve signaled by a wireless dose controller operated by the patient. The patient can release the gas at her/his own rate to make it less painful and can be done at home.  It also can speed up the process from months to weeks. The device is more expensive than saline injections but it reduces the numbers of physician’s visits, so cost is comparable. 

The process of restoring something so intimate may be embarrassing as well as medicalizing part of one’s identity.
  This device may be a way to restore lost confidence for breast cancer survivors.  Losing one’s breast can be damaging to one’s identity. We as a society equate breasts with feminine identity. Without breasts, according to society, a woman becomes less desirable or less feminine. A primary goal of reconstructive surgery is to restore the bodily image of what is socially accepted, but also what the patient wants personally. Positive body image is an important part of self-identity and confidence and positive body image connects to what is socially accepted. Although this device is arguably reinforcing the social norm that women need to have breasts, this device is ultimately restoring confidence and identity. Allowing women to have a role in this medical process allows for restoring some of that lost privacy and identity in an already emotional experience. This restored control can also have a psychological effect on the patient during recovery. In a sense, this device is following the trend of our society to favor patient autonomy and increasing patient involvement in healthcare.

But when is patient control too much? Physicians may still remain cautious with devices such as these because it is moving treatment away from the known, controlled setting of the physician’s office to the patient’s home. This is the balance between respecting patient autonomy and beneficence. The downside of using this device at home is if there are any issues during the gas release, a physician will not be there immediately. Some may argue that care outside a physician’s office is not beneficial but there are also a lot of benefits to self-administration of care like this case. This device is only a small part of the entire reconstructive process. But society should still keep in the back of its mind that physicians still have a very relevant role to play in health care decisions, no matter the location of treatment. 

April 6, 2016

Paternalists at the Gate: Those With Privilege Fight to Keep It

by Craig Klugman, Ph.D.

One of the main concepts that most medical ethics instructors teach to their students is that of autonomy—self governance.…

July 13, 2015

Do Physicians Follow the Golden Rule? Some Thoughts on End of Life Care

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">There has been a <a href="http://www.nap.edu/openbook.php?record_id=18748">lot of talk recently</a> about end of life care and how people die in America as well as important recommendations made on how effective end of life care should be provided. But there is still much work to be done. Because the nature of this work cannot be resolved by more laboratory experimentation or investment in and mastery of technology, the kind of challenge presented to our healthcare system is actually more daunting, since it relates to how physicians’ communicate with their patients. The precise question I am raising with respect to the kind of end of life care patients receive at the end of their lives is this: Do physicians follow the golden rule? Do they give their patients the chance to have the same kind death they would want for themselves and for their families? Sadly, the answer is too often, no, they often do not follow the golden rule.</p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">A recent study from Stanford University “found most physicians surveyed would choose a do-not-resuscitate or “no code” status for themselves if they were terminally ill even though they tend to pursue aggressive, life-prolonging treatment for patients facing the same prognosis.” At the same time, at 2013 JAMA study found that most seniors want to die at home or in the home of someone they know and avoid burdensome end of life treatments, yet only about 1 in 3, or less, actually do. In fact, about 1 in 3 people over 65 die still die in hospitals or ICU’s after having receiving aggressive, often burdensome, medical interventions. Of those that are moved to hospice care, 1 in 3 are there for less than three days before dying. So it’s safe to say that, though end of life care has improved for the past three decades, there are still many elderly people receiving overly aggressive, sometimes unwanted treatments, at the end of life. What are the barriers to elderly patients receiving the kind of end of life care they say they want? Let me go over two obvious ones.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
April 9, 2015

Ideological Struggles Old and New in America: The Inappropriate Use of Coercive State Authority

<p><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">The history of America from the beginning was a struggle of opposing ideological perspectives over the role of the state’s power vis-à-vis the consciences of individual citizens. The 17</span><sup style="line-height: 19.0400009155273px;">th</sup><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"> century Puritans in the Massachusetts Bay Colony basically transported to America the same kind of religious, state intrusion into the lives of individuals they were trying to escape in England by requiring citizens to subscribe to the official state religion. Fortunately, there were courageous individuals there at the time, like Roger Williams (1603-1683), who strongly resisted such requirements. Williams, prior to coming to America, had been educated at Cambridge and worked for Lord Chief Justice </span><a style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;" href="http://en.wikipedia.org/wiki/Edward_Coke">Edward Coke</a><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">. (1552-1634)</span><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">  </span><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Coke was the famous English jurist whose work provided much of the foundations of the Anglo-American legal system, and who famously “declared the king to be subject to the law, and the laws of Parliament to be void if in violation of "common right and reason”.</span><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">  </span><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">No doubt Williams’ prior education and influences from Coke, and from others like Francis Bacon (1561-1626) who taught him the way of learning through experiment and observation, helped temper his strong theological commitments in relation to his views about the proper relationship between the authority of the state and religion, and the extent to which the state could have control over the consciences of free individuals, what Williams called “soul liberty”. Williams himself did not have theological quarrels with the Puritans; however, he did not believe religious conviction could be coerced. It was on this moral and political basis, that Williams founded Rhode Island, the first state ever to have a constitution guaranteeing expansive freedom of conscience to individual citizens. Fortunately, the thinking of Williams became the mindset of the key founders, particularly Jefferson (1743-1826) and Madison (1751-1836), of the American constitutional system. (For a full account of Roger Williams’ life and influence, see the wonderful book, </span><em style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Roger Williams and the Creation of the American Soul: Church, State, and the Birth of Liberty</em><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"> by John M. Barry)</span></p> <p><strong style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;"> </span></p>
February 20, 2015

The Physician-Patient Relationship: The basis for moral clarity in clinical ethics

<p><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">It is my sense that the majority, perhaps the vast majority, of cases on which clinical ethics consultants (CECs) are asked to consult and make an ethics recommendation, there is, or would be, a general consensus on the part of the CECs about what counts as the appropriate recommendation. However, the question arises of how clinical ethics as a field should deal with issues that come up about which there is not a clear consensus, such as in cases where a basic right to have an autonomous choice respected by the patient is pitted over and against the obligation of the physician to do no harm—the traditional tension between respect for patient autonomy and beneficence/nonmaleficence. This tension or conflict often occurs in cases of alleged medical futility where the patient or the patient’s surrogate requests a treatment option the physician deems will only cause harm and no benefit to the patient. For example, consider a patient’s surrogate who insists that she will not consent to a DNR order and in fact expects the physician to perform CPR if the patient arrests. For a patient without capacity dying of metastatic disease, this directive by the surrogate presents a stark dilemma to the physician—is it a violation of the physician’s obligation to the patient to “do no harm” (nonmaleficence)? Or is respect for the patient’s wishes or her representative’s wishes so sacrosanct that the physician’s obligation to follow the patient’s wishes is paramount and outweighs the obligation to do no harm?</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
February 27, 2013

A Directive Too Far

Craig Klugman, Ph.D.

For two decades, people in bioethics and medicine have extolled the virtues of advance directives. These documents allow a person to (a) list procedures, treatments, and values regarding desired future medical care and (b) designate an individual to be a surrogate decision-maker, when the patient lacks the capacity to make decisions and communicate them.

Published Articles (1)

American Journal of Bioethics: Volume 7 Issue 3 - Mar 2007

Difficult Hospital Inpatient Discharge Decisions: Ethical, Legal and Clinical Practice Issues