Model of Decision Making

The Seven-Step Decision Model

1. Determine the facts by asking the following questions:
What do we need to know?
Who is involved in the situation?
Where does the ethical situation take place?
When does it occur?
2. Define the precise ethical issue.
3. Identify the major principles, rules and values.
4. Specify the alternatives. List the major alternative courses of action.
5. Compare values and alternatives.
6. Assess the consequences. Identify short-term, long-term, positive and
negative consequences for the major alternatives. The short-term gain or
loss is often overriden when long-term consequences are considered. This
step often reveals an unanticipated result of major importance.
7. Make a decision.
 Dr. Bernard Los Clinical Model
1. Gather information
If the patient is competent, what are her/his preferences for care?
If the patient lacks decision-making capacity, has she/he provided advance directives for
care?
If the patient lacks decision-making capacity, who should act as surrogate?
What are the views of the health care team?
What other issues complicate the case?

2. Clarify the ethical issues.

- What are the pertinent ethical issues?
- Determine the ethical guidelines that people are using.
- What are the reasons for and against the alternative plans of care?

3. Resolving the dilemma.

- Meet with the health care team and with the patient or surrogate.
- List the alternatives of care
- Negotiate a mutually acceptable decision

The patients should play an active role in decision everything should be done to ensure that she/he
has been well informed by providng information in an easy-to-understand way.
 The Prudent Person Rule
also called the reasonable person standard

means that a physician must provide information to a patient that a

reasonable, prudent person would want before she/he makes a
decision about treatment or refusal of treatment.

in general, such a person would want to know:

the diagnosis
the risks and potential consequences of the treatment, excluding any
remote or improbable outcomes; the information should include the
success and failure rates of the physician and institution
the expected benefits of the treatment or procedure
potential alternative treatments
the prognosis if no treatment is received
the costs, including the amount of expected pain
 Confidentiality
Refers to keeping private all information about a patient
and not disclosing it to a third party without the patients
written consent
The duty of medical confidentiality is an ancient one:The
Hippocratic Oath states: What I may see or hear in or
outside the course of the treatment which of no
account may be spread abroad, I will keep to myself,
holding such things shameful to speak about
The objectives of medical confidentiality:
- to respect the patients privacy
- to encourage the patient to reveal useful diagnostic
information to her/his physician
 Informed Consent
The voluntary agreement given by a patient to the
proposed course of treatment after having been told
about the possible consequences of having or not having
certain procedures and treatments.
The physician is required to explain in an understandable
language:
The patients medical condition
The objectives of the proposed treatment
The advantages and risks of treatment
The alternative treatments available to the patient
Potential outcomes of the treatment
What might occur, both risks and benefits, if treatment is
refused.
 Informed consent
The physician must be honest with the
patient and tell the truth while explaining
the diagnosis, the purpose of the
proposed treatment and the probability
that the treatment will be successful.
The Prudent Person Rule of the
reasonable person standard is used.
 Criteria for fully informed or ideal
consent
1. The physician sufficiently informs, i.e.
provides a basic understanding of the problems
to the patient, and the patient adequately
understands (and has sufficient time to reflect)
2. The patient acts voluntarily (without coercion)
3. The patient is fully competent (mental
capacity) (psychological competence)
4. The patient is majority age (legal competence)
 Criteria for partially informed consent in the
emergency room (patient legally, but not fully
psychologically competent)
When one or more factors noticed above as
1- 4 is present only to a modest degree;
Adequate time is unavailable for discussion
with the patient;
The patients mental status (psychological
competency) undergoes changes during
time in the ER
 Partial Informed Consent
In those cases in which the intervention
holds a reasonable chance of providing
sufficient benefit to the patient ( the risk-
benefit ratio is sufficiently good) and where
neither the patients fully informed consent
nor his/her formerly expressed wishes is
obtainable, it is permissible to initiate
treatment (the more favourable the risk-
benefit ratio, the more justifiable the
initiation of the intervention)
 Partial Informed Consent
If the patient regained his/her
competency, he/she should be informed
afterwards and given the opportunity to
consent to or to refuse further treatment
(the deferred-consent)
 Faces of competence
18 > Mature minors >= 16yrs old
The youngsters aged 16 and over are deemed
psychologically competent to consent to medical treatment
and to begin any medical intervention you must obtain
their consent along with that of their legal guardian (in
Poland and many other countries)
Emancipated minors a person who is not legally an adult
but who, because he or she is married, in the military, or
otherwise no longer dependent on the parents, may not
require parental permission for medical or surgical care.
State and national laws vary in specific interpretations of
the rule.
 Informed Consent
The patients signature on the consent form
indicates that the patient understands the limits
or risks involved in the pending treatment or
surgery as explained by the physician.
Examples of the medical procedures in which
the patients signature on an informed consent
form is required by the state laws:
HIV testing
Procedures involving reproduction
Major surgical procedures
 Informed Consent
Examples of other procedures in which an
informed consent form should be signed:
Minor invasive surgery
Organ donation
Radiological therapy
Electroconvulsive therapy
Experimental procedures
Chemotherapy
Any procedure with more than a slight risk of harm to
the patient
 Refusal to grant consent
Adult patients who are conscious and
considered to be mentally capable have a right
to refuse any medical or surgical treatment. The
refusal must be honoured no matter what the
patients reasoning (concern about the success
of the procedure,lack of confidence in the
physician, religious belief, etc.)
Failure to respect the right of refusal could result
in liability for assault and battery.
 Exceptions to the Informed
Consent Rule
Are unique to each state
Some of the more general ones:
A physician need not inform a patient about risks that are
commonly known (e.g.that he/she could choke swallowing a pill)
A physician who believes the disclosure of risks may be
detrimental to the patient is not required to disclose them (e.g.if
a patient has a severe heart condition that may be worsened by
an announcement of risks)
If the patient asks the physician not to disclose the risks, then
the physician is not required to do so
Emergency situations formerly described
Patients under 16 yrs or legally incompetent
because of intellectual disability
There is a minimal threshold of the legally
incompetent patient decision-making
capacity necessary for her/his wishes to
be respected it refers
The criteria of the threshold capacity vary
depending on the balance of risks and
benefits of the proposed treatment:
Patients under 16 yrs or legally incompetent
because of intellectual disability
If such a patient refuses treatment that
involves high benefit and low risk, then
relatively stringent criteria shoud be
adopted in order to assess his/her ability to
make decisions, that is,
The more the patients decision appears
contrary his/her well-being, the greater the
evidence required that he/she has capacity
of making decision.
 Gillick competence (the UK &
US term)
The Gillick case concerned the provision of
contraceptive treatment, but the term Gillick
competence can be applied generally to any
patient aged under 16 who is judged able to
consent to treatment.
Gillick competent patients are sufficiently
mature to understand the nature, purpose,
potential risks and the alternatives of a
treatment.
 Gillick competence
That ability will vary with age, the child and
the type of procedure
For example, a 12-year-old may be able to
understand the nature and purpose of
simple antihistamines for hay fever but the
same may not be true with extensive
orthopaedic treatment.
 Gillick competence
If a child is not Gillick competent, the parents or
those with parental responsibility must authorise
treatment on the child's behalf.
If a Gillick competent child refuses consent, this
will not necessarily override authorisation given
by someone with parental responsibility or the
court. However, such authorisation means
treatment could be undertaken against the
child's wishes.
 Gillick competence
In deciding whether a particular treatment is in a
child's best interests, a doctor needs to consider
the consequences if the child's condition is left
untreated and also the effect of imposing
treatment on the child.
Doctors should also bear in mind the child's age
and emotional development and the nature and
possible consequences of the proposed
treatment. Medico-legal - Understanding Gillick competence
By Dr Emma Cuzner, 03 March 2011
 Patient legally incompetent
'You should involve young people as
much as possible in discussions about
their care, even if they are not able to
make decisions on their own.
The GMC guidelines
 Assent
Informed consent means approval of the legal
representative of the child and/or of the competent
child for medical interventions following appropriate
information. National legal regulations differ in
regard to the question when a child has the full
right to give his or her autonomous consent.
Informed assent means a child's agreement to
medical procedures in circumstances where he or
she is not legally authorised or lacks sufficient
understanding for giving consent competently.
 Assent
Doctors should carefully listen to the opinion and
wishes of children who are not able to give full
consent and should strive to obtain their assent.
Doctors have the responsibility to determine the
ability and competence of the child for giving his
or her consent or assent. All children, even those
not judged as competent, have a right to receive
information given in a way that they can
understand and give their assent or dissent.
 Assent
This consent/assent process must
promote and protect the dignity, privacy
and confidentiality of the child and his or
her family. Consent or assent is required
for all aspects of medical care, for
preventive, diagnostic or therapeutic
measures and research.
 Assent
Children may effectively refuse treatment or
procedures which are not necessary to save their
lives or prevent serious harm. Where treatment
is necessary to save a life or prevent serious
harm, the doctor has the duty to act in the best
interest of the child. However, parents may also
refuse to consent and in this case national laws
and legal mechanisms for resolving disputes
may be used. (Eur J Pediatr. 2003 Sep;162(9):629-33. Epub 2003 Jul 19.
Informed consent/assent in children. Statement of the Ethics Working Group of the Confederation of European Specialists in
Paediatrics (CESP).
De Lourdes Levy M1, Larcher V, Kurz R; Ethics Working Group of the Confederation of European Specialists in Paediatrics (CESP).
 Methods of Obtaining Valid
Consent
1.Informed consent
Given by a competent patient directly to a physician
(orally or/and in writing)
Given by a competent patient in advance directives
(living will)
2. Surrogate decision making
Given on behalf of the patient by:
- A health care proxy appointed by the patient in
advance directives (durable power of attorney)
- A legal guardian: parents or a person appointed by
the court
 Surrogate decision
Is based upon the wishes of the patient
if they are known
If the patients wishes are not known
decision is based on the best interest of
the patient
 Good Samaritan Law
The emergency exception to the rule of
informed consent
(Good Samaritan is someone who gives
help to people in trouble or need without
thinking of himself/herself)
 Good Samaritan Laws
Are state laws that help to protect from liability health
care professionals (in some jurisdictions also
laypersons) who provide emergency care to an accident
victim
Health care professionals (and laypeople) may be not
under a legal obligation to offer aid to an emergency
victim: e.g. in the US, only in the states of Vermont and
Minnesota there is a legal requirement of providing aid in
the event of an emergency, although at least 5 other
states (including California and Nevada) have
considered adding such a duty to their good Samaritans
statutes.

 Good Samaritan Laws

But they do have an ethical obligation to
offer such an aid (within the limits of
acquired skill and training)
The Good Samaritan laws do not protect
them from liability while practicing their
profession in their work environment (the
laws refer only to the emergency cases
outside of the work setting)
 References:
Bonnie F.Fremgen, Medical Law and
Ethics, Pearson Prentice Hall, 2006.
Terrence F. Ackerman, Carson Strong, A
Casebook of Medical Ethics, Oxford
University Press 1989.
S. F. Spicker, A contribution delivered at
the European Bioethics Seminar
Nijmegen, The Netherlands,1997.
 References
http://www.gponline.com/Clinical/article/10
57179/medico-legal-understanding-gillick-
competence/
Good Samaritan law: Wests Encyclopedia
of American Law,
http://www.answers.com/topic/good-
samaritan-doctrine
 References
Eur J Pediatr. 2003 Sep;162(9):629-33. Epub 2003 Jul 19.
Informed consent/assent in children. Statement of the Ethics
Working Group of the Confederation of European Specialists in
Paediatrics (CESP).
De Lourdes Levy M1, Larcher V, Kurz R; Ethics Working Group of
the Confederation of European Specialists in Paediatrics (CESP).
http://www.ncbi.nlm.nih.gov/pubmed/12884032