Doing what's best and best interests
http://www.100md.com
《英国医生杂志》
1 Hull York Medical School, Hull HU6 7RX
Correspondence to: John McMillan john.mcmillan@hyms.ac.uk
This case raises several important moral considerations.1 Until fairly recently people with various kinds of disability were routinely sterilised without any regard for their wishes.2 This case is clearly different in that hysterectomy was proposed as a treatment for a medical problem and not merely as contraception. People with disabilities are often assumed to lack the decision making ability or competence required to make a treatment decision simply because they have a disability. Again, this case is different because Miss Webb took part in the decision making process and efforts were made to help her think through the implications of this surgery. It is important that all people are presumed to have the competence to consent to treatment, a principle that has been embodied in the new Mental Capacity Act.3
Competence
As some respondents on bmj.com noted, if Miss Webb has the competence to make this decision her consent is sufficient for authorising treatment (assuming that it was also voluntary and informed). Her doctors should consult the advice outlined in the Mental Capacity Act about determining competence in such cases.
Competence functions as a threshold concept.4 In other words, when a person is deemed competent he or she has the right to consent to or refuse treatment and when a person is deemed incompetent a best interests' decision should be made. In reality, we all experience varying degrees of misunderstanding, irrationality, vulnerability, and dependence when faced with an important medical decision. So while competence might sort us neatly into one of these two categories, it is important that doctors do what they can to help all patients make the right decision for them.
The question of what is best for Miss Webb is of central importance, as some respondents pointed out. This observation is at the heart of a problem relating to the way that we often think about consent. Consent is increasingly seen as able to solve all moral questions (a good example of this is the Human Tissue Bill5). When patients are deemed competent to make a decision, it is still important to be sure that treatment is in the patient's interests. Even though best interests cannot trump the competent refusal of treatment and is not of primary legal importance for consent by a competent adult, it is of moral importance in both kinds of case. Beneficence requires us not only to do what we can to enhance the patient's opportunity to make the right decision but also to reason with them when we think that they are making a mistake.
A hysterectomy to control menorrhagia is a major decision for a woman in her 20s who does not have Down's syndrome, and it is just as important for Miss Webb. As one respondent noted, Miss Webb's values are what matter most in this case. Other respondents suggested it might be appropriate to involve several people in this decision to be sure that hysterectomy is in fact what's best. The acid test for this case is what Miss Webb thinks about her surgery now. If she continues to endorse this decision, all concerned can have confidence that the best thing has happened.
Competing interests: None declared.
References
Siotia AK, Chaudhuri A, Muzulu SI, Harling D, Muthusamy R. Postoperative hypoxia in a woman with Down's syndrome: case outcome. BMJ 2005;330: 1068.
Kevles D. Eugenics and human rights BMJ 1999;319: 435-8.
Department for Constitutional Affairs/Mental Capacity Act 2005. www.dca.gov.uk/menincap/legis.htm (accessed 21 Apr 2005).
Buchanan A, Brock D. Deciding for others: the ethics of surrogate decision making. Cambridge: Cambridge University Press, 1990: 26.
UK Parliament. Human Tissue Bill 2005. www.parliament.the-stationery-office.co.uk/pa/cm200304/cmbills/009/04009.i-v.html (accessed 21 Apr 2005).(John McMillan, senior lecturer in medica)
Correspondence to: John McMillan john.mcmillan@hyms.ac.uk
This case raises several important moral considerations.1 Until fairly recently people with various kinds of disability were routinely sterilised without any regard for their wishes.2 This case is clearly different in that hysterectomy was proposed as a treatment for a medical problem and not merely as contraception. People with disabilities are often assumed to lack the decision making ability or competence required to make a treatment decision simply because they have a disability. Again, this case is different because Miss Webb took part in the decision making process and efforts were made to help her think through the implications of this surgery. It is important that all people are presumed to have the competence to consent to treatment, a principle that has been embodied in the new Mental Capacity Act.3
Competence
As some respondents on bmj.com noted, if Miss Webb has the competence to make this decision her consent is sufficient for authorising treatment (assuming that it was also voluntary and informed). Her doctors should consult the advice outlined in the Mental Capacity Act about determining competence in such cases.
Competence functions as a threshold concept.4 In other words, when a person is deemed competent he or she has the right to consent to or refuse treatment and when a person is deemed incompetent a best interests' decision should be made. In reality, we all experience varying degrees of misunderstanding, irrationality, vulnerability, and dependence when faced with an important medical decision. So while competence might sort us neatly into one of these two categories, it is important that doctors do what they can to help all patients make the right decision for them.
The question of what is best for Miss Webb is of central importance, as some respondents pointed out. This observation is at the heart of a problem relating to the way that we often think about consent. Consent is increasingly seen as able to solve all moral questions (a good example of this is the Human Tissue Bill5). When patients are deemed competent to make a decision, it is still important to be sure that treatment is in the patient's interests. Even though best interests cannot trump the competent refusal of treatment and is not of primary legal importance for consent by a competent adult, it is of moral importance in both kinds of case. Beneficence requires us not only to do what we can to enhance the patient's opportunity to make the right decision but also to reason with them when we think that they are making a mistake.
A hysterectomy to control menorrhagia is a major decision for a woman in her 20s who does not have Down's syndrome, and it is just as important for Miss Webb. As one respondent noted, Miss Webb's values are what matter most in this case. Other respondents suggested it might be appropriate to involve several people in this decision to be sure that hysterectomy is in fact what's best. The acid test for this case is what Miss Webb thinks about her surgery now. If she continues to endorse this decision, all concerned can have confidence that the best thing has happened.
Competing interests: None declared.
References
Siotia AK, Chaudhuri A, Muzulu SI, Harling D, Muthusamy R. Postoperative hypoxia in a woman with Down's syndrome: case outcome. BMJ 2005;330: 1068.
Kevles D. Eugenics and human rights BMJ 1999;319: 435-8.
Department for Constitutional Affairs/Mental Capacity Act 2005. www.dca.gov.uk/menincap/legis.htm (accessed 21 Apr 2005).
Buchanan A, Brock D. Deciding for others: the ethics of surrogate decision making. Cambridge: Cambridge University Press, 1990: 26.
UK Parliament. Human Tissue Bill 2005. www.parliament.the-stationery-office.co.uk/pa/cm200304/cmbills/009/04009.i-v.html (accessed 21 Apr 2005).(John McMillan, senior lecturer in medica)