Decision Making in Incompetent Patient

Decision making in medical grounds materialized in informed consent. Informed

consent is not merely a legal document, it is grounded in one of a fundamental principle of
medicine, autonomy.
In medical ethics, we recognize the principle of autonomy, it is a general principle
that every person has a right to self-determination limited only by the equal and competing
rights of others, as written in the declaration of human right. Since a patients healthcare is
species of self determination, this become foundation of medical doctrine of informed
consent.
This principle, however, applies in assumption that the patient has a decision-making
capacity. What makes a patient competent in deciding what is best for him, in their health
manner? There are three requirements to be met in order for this competency: The patient
must have the ability to understand the nature and implications of the options that are being
presented; must have stable and competent values, such as religion and beliefs; and must be
able to make free choices without being coerced.
Incompetent patient is one that does not meet one or more requirements above. Young
children, individuals affected by psychiatric or neurological conditions and those who are
temporarily unconcious or comatose. According to World Medical Association Ethics
Manual, these patient require substitute decision-makers or surrogates.
Kluge divides incompetent patients in two groups, previuosly competent patient and
never been competent patient. This division made because this two divisions has different
values and expectation to be regarded by the surrogates.
In a previously competent patient, he/she may previously appointed a subtitute
decision-making before he/she become incompetent, this is an ideal condition where the
substitute (family related or not) has the same values as the patient therefore the decision
made by the substitute is ideal or in the patients health interest. If this condition does not
met, a commonly accepted order of substitute has been identified in our society: spouse,
child, parent, sibling and anyone else related by birth or adoption. This order could be
overruled by a court of law if there is a dispute in the order or the values of the substitute.
In an emergency situation, however, where the designated substitute does not appear,
the physician may act as a substitute. The physician may decide to perform any intervention
needed unless the patient is obviously and beyond any doubt on the basis of the patients
previous firm expression or conviction that he/she would refuses to do so.
In a never been competent patient, values and appointment are not available.
Wilkinson proposed a Treshold viewas a tool to help family, as a surrogate, to made a
decision, especially in a severely impaired newborn infants. His proposal is to determine if a
life worth living for the newborn. The definition of a life worth living, though provocative, is
A life in which future benefits for the individual outweigh the burdens. There is positive net
future well-being. And the definition of life not worth living as A life in which future
burdens for the individual outweigh benefits. There is negative net future well-being. These
definitions, measured by medical expert, may help family to decide whether medical
salvation needed for the infant.
Kluge developed 5 models of currencies to help surrogate making decision regarding
their surrogated. They are, respectively, using the value of medical appropriateness,
mandating that the substitute use the value of family settings, doing what is in the patients
best interest as determined by the beneficence principle, using the values that the incompetent
patient would have used if the incompetent person had held values and doing everything
possible for the patient. These models are not without problems, therefore they are
situational.
Reference
Garrett-Mayer, Elizabeth, David Shalowitz, and David Wendler. "How Should Treatment
Decisions Be Made for Incapacitated Patients, and Why?" www.plosmedicine.org. March
2007. www.plosmedicine.org (accessed 09 20, 2012).
Kluge, Eike-Henner W. "Incompetent Patients, Substitute Decision Making, and Quality of
Life: Some Ethical Considerations." Medscape J Med, 2008.
Oonagh, Corrigan, and Bryn Williams-Jones. "Consent is not Enough ." The Lancet, 2003.
Sade, Robert M. "The Locus of Decision Making for Severely Impaired Newborn Infants."
The American Journal of Bioethics, 2011: 40-41.
World Health Organization. Health ethics in South East Asia. New Delhi: World Health
Organization, 2000.
World Medical Association. Medical Ethics Manual. Ferney-Voltaire Cedex, 2009.