This chapter discusses the second topic that is essential to the analysis of an ethical problem in clinical medicine, namely, the preferences of patients. By preferences of patients we mean the choices that persons make when they are faced with decisions about health and medical treatment. These choices reflect the patient’s own experience, beliefs, and values as informed by the physician’s recommendations. The previous topic, Medical Indications, concerns the physician’s clinical judgment about a patient’s medical condition and about interventions that might objectively improve deficits in that condition. When there are medical indications for treatment, a physician should propose a treatment plan that a patient may accept or refuse. We will discuss: (1) The ethical principle of respect for the autonomy of the patient; (2) the legal, clinical, and psychological significance of patient preferences; (3) informed consent; (4) decisional capacity; (5) truth in medical communication; (6) cultural and religious beliefs; (7) refusal of treatment; (8) advance directives; (9) surrogate decisions; (10) the challenging patient; and (11) alternative medicine.
2.0.1 The Principle of Respect for Autonomy
Respect for autonomy is the guiding ethical principle of the Topic of Patient Preferences. Respect for autonomy is one aspect of a larger principle, namely, respect for persons, which is a fundamental principle of all morality. Respect for persons affirms that each and every person has moral value and dignity in his or her own right. In this sense, the principle of respect applies to every encounter between persons, regardless of their situation, stage, or state of life. One implication of respect for persons is a respect for personal autonomy, that is, acknowledging the moral right of every competent individual to choose and follow his or her own plan of life and actions.
In clinical ethics, respect for the autonomy of the patient signifies that physicians’ judgments about how to benefit their patients should include the values of the patients themselves. Physicians must never ignore or override the preferences of their patients. Patients’ responses to physicians’ recommendations should reflect their own values for their own lives. Patients have the right to freely accept or reject a physician’s recommendations.
As a moral principle, respect for autonomy is a “two-way street”: treating physicians also have autonomy to use on their best judgment about how best to benefit a patient medically. Therefore, respect for patient autonomy does not imply that patients have the right to demand inappropriate treatment; neither does it imply that a physician must accede to any and every request of a patient if it conflicts with the physician’s best judgment.
In clinical ethics, respect for patient preferences takes place within a patient-doctor relationship, that is, when some health problem prompts a patient to seek help from a physician and a physician responds with diagnosis, advice, and a proposed treatment. In this therapeutic relationship, physicians possess knowledge and skills ...