Abstract
Mr. Tas is a 65-year-old man who formerly owned a restaurant and is presently working as manager in another restaurant. He had always enjoyed good health until one Saturday during a dinner party with some friends he suddenly passed out while getting up from a chair. Other symptoms included some coughing, the production of yellowish sputum and fever.
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A VQ scan is a ventilation-perfusion scan. This scan makes ventilation (air) and perfusion (blood) of the lungs visible. When there is a ‘mismatch’ (ventilation but no perfusion in a certain part of the lung) this indicates a pulmonary embolism. Absolute certainty about the presence or absence of an embolism can only be obtained with a pulmonary angiography that is a more invasive procedure.
For a pulmonary angiography, a probe is carried up to the lungs through a vessel in the groin in order to inject the contrast. The groin needs to be shaved for that purpose.
In the case of Mr. Tas, for example, the physician wanted to perform more diagnostic tests in order to get a proper diagnosis while in the meantime Mr. Tas himself was getting impatient and just wanted to go home. From the perspective of the physician, there were abnormalities in Mr. Tas’ physical functioning that should be explained. From Mr. Tas’ perspective, once he knew that he was “all right”, the question of the proper diagnosis was not very important anymore.
A co-assistant is a medical student in the last clinical phase of his or her education.
In one of the earliest qualitative studies of medical decision-making and informed consent, Lidz et al. already concluded: “Seldom does the doctor see a series of alternative possible treatments. Rather, for each problem there typically exists a medically preferable treatment, not a series of alternatives from which the patient may choose. It does not seem to the doctor to be a decision-making process but simply a question of persuading the patient to accept proper treatment. The decision has been made — by the doctor. It is now, in the medical view, time to make a recommendation to the patient” and a little further: “in the doctor’s view there is no decision for the patient to make, except whether or not to get proper medical care” (1982, 399–400).
Another way in which protocols tend to limit the role of the patient in the decision-making process is by contributing to a “loss of importance of information and interventions which are difficult to explicate and/or to quantify” (Berg 1997, 1085). Berg mentions the social circumstances of the patient and the tone of a conversation as examples of such information. It seems as if a lot of information crucial to detennining what a patient considers to be for his own good and a lot of interventions directed to including the patient’s point of view in decision-making are difficult to explicate and certainly difficult to quantify. One cannot measure the fear of a patient for a procedure, and this automatically makes it a less important piece of information than the evidence-based risk and success rates. Moreover, it is much more difficult to give standardised and scientifically sound instructions for discussing such fear with a patient than it is to make a protocol for a state-of-the-art implementation of the procedure.
Still, whether in such a case it is the unpleasantness or the health risks of the procedure that are considered to be the most important reason for this course of action is not clear.
Laine and Davidoff describe this change as a “professional evolution” (Laine & Davidoff 1996). Faden and Beauchamp describe it in terms of a replacement of a beneficence model by an autonomy model. Though the efforts of lawyers and ethicists have certainly contributed to these changes, other factors such as the various civil rights movements, the Nuremberg trials, and the increasingly technological and impersonal character of medical care had a great influence as well (Faden and Beauchamp 1986, 86–88).
In the case of diagnosis and treatment of eusophagus varices due to chirrosis of the liver, a Dutch court has ruled that physicians should at least inform patients that various opinions exist on the best course of action and should offer the patient the possibility to go to another hospital that follows different guidelines and offers different options (Gerechtshof Amsterdam 1998).
Standard therapy after thrombosis is three months of acenocoumarol. Standard therapy in atrial fibrillation is acenocoumarol for as long as the atrial fibrillation lasts, probably the rest of one’s life. Atrial fibrillation enhances the chances of embolism (blood cloths) that can damage organs such as the brain or kidneys; acenocoumarol diminishes this risk.
Nurses are often depicted as the patient’s advocates and they generally pay more attention to patients’ individual goals, preferences, hopes and fears. The biomedical perspective is less present in nursing practice than it is in medical practice. However, as The (1997) has clearly shown, nurses have difficulties in making themselves heard, precisely because they do not speak the language of the biomedical perspective.
Barnard uses the term ‘materialism’, but from his explanation this appears to be equivalent to what I have called the biomedical perspective.
Take, for instance, the availability of alternatives discussed previously. For a more extensive discussion of the value-laden and constructed character of medical facts, see Brock 1993 and Berg 1992.
Mr. Tas’ perspective may not have been all that different from the biomedical perspective, and in his case, the biomedical logic probably did not obscure relevant alternatives. There was a woman on the same ward, however, who had been told that her uterus should be removed because it threatened her health. For several reasons, this woman very much wanted to keep her uterus even if this meant some health risks. Her reasons and point of view were hardly discussed with her at all, and no effort was made to find alternatives because the physicians involved only looked at the issue from a biomedical point of view and found it only logical that the uterus should be removed.
Research has shown that patients do not want to do so either. “Given the choice between abiding by the decisions of a paternalistic provider and being handed a stack of medical books and told to figure out what they wish to do, most patients unsurprisingly opt to hand over control to the trusted provider” (Deber, Kraetschmer & Irvine 1996).
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© 2002 Springer Science+Business Media Dordrecht
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Schermer, M. (2002). What’s There to Decide for Mr. Tas?. In: The Different Faces of Autonomy. Library of Ethics and Applied Philosophy, vol 13. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9972-6_5
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DOI: https://doi.org/10.1007/978-94-015-9972-6_5
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