The Moral Significance of Non-Autonomous Refusals of Medical Treatment Público

Abstract

In contemporary medical ethics, the theoretical justification for informed consent has been extended to treatment refusal decisions. This has rendered a theoretical framework in which compulsory treatment of non-autonomous patients (those lacking decisionmaking capacity) is justified solely by reference to their lack of decision-making capacity. The result is that an active refusal by a non-autonomous patient may be automatically overridden by the consent of a surrogate decision maker. The primary objective of this thesis is to make the case that the nature of an active refusal is such that lack of decision-making capacity should not automatically negate one's right to refuse medical treatment. I will argue that a refusal contains a moral significance, the source of which is one's negative liberty rights, that is independent of a patient's decision-making capacity. Therefore, if a non-autonomous patient is to be treated against his or her expressed wishes, the treatment must be justified on grounds in addition to his or her lack of decision-making capacity. The secondary objective of this thesis is to propose a principle that balances the moral significance of a non-autonomous patient's refusal with the obligation to protect him from the consequences of his decisions. I will argue that a harm principle accomplishes this task and is the appropriate threshold for determining whether overriding the patient's expressed refusal is justified.

Table of Contents

Table of Contents CHAPTER 1 ................................................................................................................................... 1 Informed Consent, Decision-Making Capacity, and Refusal ....................................................... 2 The Structure of Autonomy ......................................................................................................... 7 Decision-Making Capacity .......................................................................................................... 8 Relationship Between Agency and Liberty ................................................................................. 9 The Five Dimensions of Autonomy ........................................................................................... 15 Structure of Autonomy Along the Five Dimensions.................................................................. 18 Can Forced Treatment Be Justified? .......................................................................................... 19 CHAPTER 2 ................................................................................................................................. 21 Autonomy and Informed Consent .............................................................................................. 21 What is Informed Consent? ....................................................................................................... 26 Autonomous Refusal of Treatment ............................................................................................ 31 Decision-Making Capacity and Surrogate Decision Making ..................................................... 37 Does Consent of a Surrogate Nullify a Patient's Active Refusal? ............................................. 41 Capacity and the Consequences of Refusal ............................................................................... 47 Should We Respect All Refusals? ............................................................................................. 50 CHAPTER 3 ................................................................................................................................. 52 Isaiah Berlin and Two Concepts of Liberty ............................................................................... 54 Negative Liberty ........................................................................................................................ 55 Positive Liberty .......................................................................................................................... 56 The Relationship Between Positive and Negative Liberty ........................................................ 57 Medical Decision-Making Capacity as Positive Liberty ........................................................... 58 Objections to Berlin's Distinction ............................................................................................. 60 Christman's Content-Neutral Conception of Positive Liberty ................................................... 61 Richard Fallon's Concept of Ascriptive Autonomy................................................................... 70 CHAPTER 4 ................................................................................................................................. 73 Paternalism ................................................................................................................................ 73 Person-Mediating Maxim versus Act-Mediating Maxim .......................................................... 74 Paternalism in the Case of Non-Autonomous Active Refusal ................................................... 75 Harm Principle ........................................................................................................................... 80 The Case of Ryan ....................................................................................................................... 87 Conclusion ................................................................................................................................ 91 BIBLIOGRAPHY .......................................................................................................................... 93

About this Master's Thesis

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School	Laney Graduate School
Department	Bioethics
Degree	MA
Submission	Master's Thesis
Language	English
Research Field	Philosophy Health Sciences, Mental Health
Palavra-chave	Bioethics Liberty Agency Paternalism Informed Consent Autonomy Patient Refusal Decision-Making Capacity
Committee Chair / Thesis Advisor	Schonfeld, Toby, Emory University
Committee Members	Labrecque, Cory A, Emory University Risjord, Mark, Emory University

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