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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