Patient autonomy and evidence-based choice – philosophical and ethical perspectives

Moore, Willem (2010-03)

Thesis (DPhil (Philosophy))--University of Stellenbosch, 2010.

Thesis

ENGLISH ABSTRACT: This study involves a critically evaluation of evidence-based patient choice as partnership model in clinical decision making. It pays attention to the emergence of the concept of autonomy in modern moral philosophy and in particular to the pivotal contributions of Immanuel Kant and John Stuart Mill in this regard. Against this background, it elaborates on the ethical principle of respect for autonomy, informed consent as paradigm for patient autonomy in clinical decision making, the conflicts that arise between the ethical concepts of autonomy and beneficence, the dominance of paternalism in clinical decision making, the challenges posed to the dominance of paternalism, the resulting emergence of the concept of partnership in clinical decision making and evidence-based patient choice as partnership model in clinical decision making. Moreover, it provides an exposition of the context, nature and practice of evidence-based patient choice and of the four key decision making skills required from health care professionals to involve patients in clinical decision making, namely shared decision making, risk communication, decision analysis, and the use of decision aids. Against this background, it critically evaluates the effectiveness of evidence-based patient choice as partnership model in clinical decision making by judging it in terms of the ethical concept of patient autonomy as reflected in the informed consent elements of competence, disclosure, understanding and voluntariness and indicates that none of the key skills of evidence-based patient choice can be regarded as completely adequate in honouring the principle of respect for autonomy in clinical decision making and that consequently each of these four key skills leave evidence-based patient choice with a challenge that needs to be addressed from another angle in order to establish and maintain the ethical principle of respect for autonomy. In response to these challenges, the study makes three recommendations for the transformation of evidence-based patient choice to a therapeutic alliance health care, namely to review and further develop the philosophical foundations of evidence-based patient choice, to consider the continental philosophical perspectives of Edmund Husserl, Jean-Paul Sartre, Maurice Merleau-Ponty and Jürgen Habermas on the evidence-based patient choice challenges of the separate worlds of doctor and patient, the constitution of meaning in illness and the dangers of abstractions and informational manipulation in health care and to transform the practice of evidence-based patient choice to a therapeutic alliance in health care by individualising the provision of information by embedding it in the human processes of sense making, knowledge creation and decision making through which information is transformed into insight, knowledge and action.

AFRIKAANSE OPSOMMING: Die studie behels 'n kritiese evaluering van evidence-based patient choice as vennootskapsmodel in kliniese besluitneming. Dit verwys na die opkoms van moderne morele filosofie en in die besonder na die deurslaggewende bydraes van Immanuel Kant en John Stuart Mill in hierdie verband. Teen hierdie agtergrond bespreek dit die etiese beginsel van respek vir outonomie, ingeligte toestemming as paradigma vir pasiënt outonomie in kliniese bsluitneming, die moontlike konflikte tussen die etiese konsepte van outonomie en weldadigheid, die dominansie van paternalisme in kliniese besluitneming en die uitdagings wat dit ontlok het, die gevolglike ontstaan van die konsep van vennootskappe in kliniese besluitneming, asook evidence-based patient choice as vennootskapsmodel in kliniese besluitneming. Voorts verskaf die studie 'n uiteensetting van die konteks, wese en praktyk van evidence-based patient choice, asook van die vier sleutelvaardighede wat van medici vereis word ten einde pasiënte in kliniese besluitneming te betrek, naamlik gedeelde besluitneming, die kommunikasie van risikos, die analise van besluitneming en die gebruik van besluitnemingshulpmiddels. Teen hierdie agtergrond onderneem die studie 'n kritiese evaluering van die effektiwiteit van evidence-based patient choice deur dit te meet aan die ingeligte toestemming elemente van kompetensie, blootlegging, verstaan en vrywilligheid en toon aan dat geeneen van hierdie sleutelvaardighede as volledig toereikend in die nastreef van die beginsel van respek vir outonomie in kliniese besluitneming beskou kan word nie en evidence-based patient choice daarom met uitdagings laat wat vanuit 'n ander hoek bearbei moet word ten einde die beginsel in die praktyk te vestig en te onderhou. In reaksie hierop maak die studie drie aanbevelings met die oog op die transformering van evidence-based patient choice na 'n terapeutiese alliansie in gesondheidsorg, naamlik om die filosofiese grondslae van evidence-based patient choice in oënskou te neem en verder te ontwikkel, om oorweging te skenk aan die kontinentaal filosofiese perspektiewe van Edmund Husserl, Jean-Paul Sartre, Maurice Merleau-Ponty en Jürgen Habermas met betrekking tot die evidence-based patient choice uitdagings van die verskillende wêrelde van dokter en pasiënt, die konstituering van betekenis in siekte en die gevare verbonde aan die abstrahering en manipulering van inligting in gesondheidsorg en om op grond hiervan die praktyk van evidence-based patient choice te transformer. Dit sal gedoen word deur die verskaffing van inligting aan pasiënte te individualiseer deur dit in te bed in the menslike prosesse van sinmaking, kennis generering en besluitneming waardeur inligting getransformeer word tot insig, kennis en aksie.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/1393
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