The competent practice of geriatric medicine requires physicians and other clinicians to master both a body of knowledge about how to diagnose and treat geriatric health conditions and an ethic to apply this knowledge to the care of their patients. In general, the ethics of patient care focus on using the principles of respect for autonomy and beneficence. Perhaps, one of the most important mechanisms to apply these principles is informed consent: the voluntary choice of a competent patient. In these respects, geriatrics is just like fields such as cardiology and endocrinology, which have carved out a particular focus of research, education, and practice and share a common ethic to guide the care of patients.
However, geriatrics differs from other fields of medicine in a number of distinct and ethically substantive ways. Most fields are largely organized around an organ system, such as the gastrointestinal system, or around pathology, such as cancer. But geriatrics is organized around a group of persons defined by a label: the elderly. Being elderly does not simply equate to an organ system or pathology. Instead, it describes a stage in a life course, with an indeterminate beginning and features constructed out of a matrix of biological, social, political, and cultural conditions. For example, geriatric patients are often defined as persons aged 65 years and older. This age cutoff, while precise, is constructed out of the legislation that defines eligibility for state or federal retirement and health care benefits.
Of course, all medical practice is, in some manner, bound to social, political, and cultural conditions. For example, concepts of mental illness are influenced by concepts of what is “normal behavior.” Geriatricians face the challenge of negotiating the fungible borders between illness and normal aging, and between living and dying. This means that mastery of the common ethic of medicine is necessary, but it is not sufficient. This chapter addresses the ethics of medicine focused on the care of elderly patients. The focus is an ethic that addresses the relationship between the patient and the clinician—informed consent—and particular issues in informed consent that are important for the competent practice of geriatric medicine: diagnostic disclosure, advance care planning, quality of life, refusal of treatment, withdrawal and withholding of treatment, and surrogate decision making. We will also discuss the conditions that underlie decisions: voluntariness and the system of care.
The ethical foundation of making decisions with patients is informed consent: the voluntary choice of a competent patient following adequate disclosure of the relevant facts. Competency is an essential guiding principle to assure that clinicians strike a proper balance between protecting patient autonomy and promoting patient welfare. In other words, competency provides a tool to balance the two ethical principles of respect for autonomy and beneficence. A competent patient should be allowed to choose even if the choice is harmful or “goes against medical advice.” In contrast, an incompetent patient is not allowed to choose. This denial of ...