00:01
In the past lecture
on informed consent,
we talked about the patient's
ability to make their own decisions.
00:08
There are going to be situations
where we encounter patients
where it's not really
clear whether or not
they have the capacity
to make decisions.
00:15
So this lecture is going
to go through a process
of thinking about
decision making capacity.
00:22
If you recall from
the lectures that
we talked about
with ethical theory,
we talked about
respect for autonomy,
and there are certain conditions
to being an autonomous agent,
be able to be a person
that can make decisions.
00:35
The first element or first condition
is that you have intentionality.
00:39
So if you're going
to perform an action,
that you have the intent
of performing that action,
and that usually means that
it's consistent or corresponds
with the individuals
conception or plan.
00:51
So they intend the action they
follow through and having the action.
00:55
Another condition for
autonomy is understanding.
00:58
So when we're thinking
about decision making,
they have to have
a knowledge base
by which to make
their decisions.
01:04
It doesn't mean they
have to know everything.
01:06
It's not omniscience
that we're after,
but at least,
especially for medical decisions,
the idea that they have a
understanding of the nature
of the action that they
are intended to perform,
as well as the
foreseeable consequences,
or outcomes to be
expected from that decision.
01:25
And then lastly,
there has to be voluntariness.
01:27
We mentioned this in the
informed consent lecture.
01:29
But this is another place
where we really make sure
that the patient is free
from any external control
in making their own decisions
or performing their own actions.
01:38
So sort of those are the
conditions for autonomy.
01:43
So let's talk a little bit
more about voluntariness.
01:46
So that means not
being under the control,
or undue influence
of another person.
01:52
And there can be various ways
that a person could be influenced.
01:55
And here are some of the
categories of influences on a person.
02:00
So maybe there's persuasion.
02:02
So you're trying to
convince a person
to make a certain decision
or perform a certain action.
02:07
So you're using reasoning
trying to reason with them
have a discussion
with them trying to
persuade them of a
certain course of action.
02:16
And that generally is going
to be considered permissible
when we're thinking about informed
consent in the medical setting.
02:23
Where it starts to become
concerning in terms of categories
of influence would be
something like manipulation.
02:29
So you're altering
the information
or how you're relaying
it to the patient
in order to achieve
a certain goal.
02:34
You're trying to
convince them or unduly
persuade them about
reaching a decision.
02:40
So that kind of manipulation
may not be morally permissible.
02:44
And lastly, for sure,
coercion is morally impermissible.
02:49
Any kind of threat of harm or
undue influence of the individual,
you have to avoid,
we really want the person to make decisions
voluntarily of their own
freewill that's being autonomous.
03:04
So the other precondition
for informed consent
besides voluntariness is
decision making capacity.
03:10
So it's really one
of the core features,
the need to assess as you're going
through the informed consent process.
03:18
And what does it actually mean,
it means the patient is able
to understand the information
that's given to them,
manipulate that information
using their reasoning ability,
in order to make and communicate
a decision to the clinician.
03:31
And it's important to
recognize that all adult patients
are presumed to have
capacity until proven otherwise.
03:38
So prima facie,
you know, on first blush,
we are saying,
patient is going to have capacity,
It's only when there
might be red flags
that we'll talk about
in future lecture,
where we might say, well,
maybe we need to assess,
does this person have the ability
to make their own decisions?
There going to be
four main aspects
that are required for
decision-making capacity.
04:02
The first that we focused on
in the informed consent lecture
is this idea of understanding.
04:06
So being able to
comprehend the medical
information that's
being given to them.
04:12
Second,
an appreciation of that information,
really how it's significant to
them in their own life situation.
04:20
So perhaps they're given a diagnosis,
they're given a prognosis.
04:24
They're told about
treatment options,
they have to put that in
the context of their own life
and appreciate the
impact of the disease
and the treatment
on their life situation.
04:38
Next, another aspect of decision-making
capacity is their reasoning ability.
04:43
So if they're given, you know,
a broad range of information.
04:46
If they're given alternatives,
you know,
the physician might
recommend one line
of treatment but are
given alternatives.
04:54
They then have to decide,
how is this going to work for me?
Reason through the options and then
make a decision based on their values
and the consequences of the
decision that they can foresee.
05:08
And ultimately,
they have to make a choice.
05:11
They have to communicate back.
05:12
Yes, I've heard the information
and I've understood the information.
05:15
I've reasoned through it,
sort of appreciate it
in sort of who I am as a person.
05:20
And now I'm making a decision.
05:22
"This is what I want to
do about the treatment."