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Correspondence |

Patients’-Best-Interests Standard Trumps Autonomous Health-care Decisions: Paternalism vs Self-Determination FREE TO VIEW

Mohamed Y. Rady, MD, PhD; Joseph L. Verheijde, PhD
Author and Funding Information

From the Department of Critical Care Medicine, Mayo Clinic Hospital (Dr Rady); the Departments of Biomedical Ethics and Physical Medicine and Rehabilitation, College of Medicine, Mayo Clinic (Dr Verheijde); and the Center for Biology and Society, School of Life Sciences, Arizona State University (Drs Rady and Verheijde).

Correspondence to: Mohamed Y. Rady, MD, PhD, Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, AZ 85054; e-mail: rady.mohamed@mayo.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(4):1021-1022. doi:10.1378/chest.10-0939
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To the Editor:

The Patient Self-Determination Act upholds patient autonomy to accept or refuse a treatment and obligates clinicians to comply with advance health-care planning and directives and authorized health-care proxy. Tonelli and Misak (April 2010)1 posited the following conditions for overriding adult patients’ (and surrogates’) treatment decisions when the choices are no longer autonomous: (1) disagreement exists between clinicians and the patient or surrogate, (2) the patient may have impaired decision-making capacity, and (3) a high-stakes decision must be made. Because clinicians are in a privileged position (ie, they understand the prognosis and the benefits and burdens of treatment), they can dictate treatment decisions contrary to patient/surrogate choices based on the best interests standard. As described by Tonelli and Misak, this standard is “…understood as a standard of reasonableness, guiding [clinicians] to select as most informed and rational individuals would…and [decisions] could be made without a thorough understanding of the patient’s goals and values [emphasis added].” The authors consider this standard as shared decision making instead of paternalism (eg, overriding a Jehovah’s Witness’ transfusion refusal in a life-threatening situation). This standard raises several issues.

In shared decision making, two parties (ie, the clinician and the patient/ surrogate) voluntarily reach an agreement.2 In the best interests standard, a unilateral decision is invoked when disagreement exists between parties.

Clinicians’ predictions of patients’ prognoses and treatment benefits, burdens, and responses vary widely.3 No objective criteria or consensus exist on what constitutes the best interests standard. Few clinicians are willing to assume directive roles and full responsibility when making high-stakes decisions.2 Therefore, clinicians may resist dictating treatment decisions based on an ambiguous standard.

Treatment preferences are inseparable from moral, cultural, and religious values in patient-centered care.4 Disagreements on value-sensitive decisions arise when the diversity of these values in a pluralistic society is disregarded.5 A best interests standard that transgresses a patient’s values cannot be viewed as a commitment to patient autonomy.

Undisclosed competing interests, some of which have serious consequences, may also shape the best interests standard. For example, procurement coordinators and clinicians do not disclose their collaboration in maximizing end-of-life organ procurement to seriously ill patients or surrogates.6 Clinicians are in dual relationships (physician/patient vs organ harvester/potential donor) with conflicting advocacy roles.7 Failing to manage these conflicting roles can conflate the best interests standard with an incentive to procure organs.

Finally, the law, in an effort to safeguard autonomy, has set a high threshold in determining decisional incapacity. Invoking the best interests standard, instead of following advance directives, can result in legal penalties in 24 states.8 In conclusion, we believe that Tonelli and Misak should have posited, instead, how to sharpen the boundary between self-determination and paternalism.

Tonelli MR, Misak CJ. Compromised autonomy and the seriously ill patient. Chest. 2010;1374:926-931. [CrossRef] [PubMed]
 
White DB, Malvar G, Karr J, Lo B, Curtis JR. Expanding the paradigm of the physician’s role in surrogate decision-making: an empirically derived framework. Crit Care Med. 2010;383:743-750. [CrossRef] [PubMed]
 
Azoulay É, Metnitz B, Sprung CL, et al; SAPS 3 investigators SAPS 3 investigators End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med. 2009;354:623-630. [CrossRef] [PubMed]
 
Sprung CL, Maia P, Bulow H-H, et al; Ethicus Study Group Ethicus Study Group The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;3310:1732-1739. [CrossRef] [PubMed]
 
White DB, Evans LR, Bautista CA, Luce JM, Lo B. Are physicians’ recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med. 2009;1804:320-325. [CrossRef] [PubMed]
 
Shafer TJ, Wagner D, Chessare J, et al. US organ donation breakthrough collaborative increases organ donation. Crit Care Nurs Q. 2008;313:190-210. [PubMed]
 
Luskin RS, Glazier AK, Delmonico FL. Organ donation and dual advocacy. N Engl J Med. 2008;35812:1297-1298. [CrossRef] [PubMed]
 
Iltis AS, Rie MA, Wall A. Organ donation, patients’ rights, and medical responsibilities at the end of life. Crit Care Med. 2009;371:310-315. [CrossRef] [PubMed]
 

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References

Tonelli MR, Misak CJ. Compromised autonomy and the seriously ill patient. Chest. 2010;1374:926-931. [CrossRef] [PubMed]
 
White DB, Malvar G, Karr J, Lo B, Curtis JR. Expanding the paradigm of the physician’s role in surrogate decision-making: an empirically derived framework. Crit Care Med. 2010;383:743-750. [CrossRef] [PubMed]
 
Azoulay É, Metnitz B, Sprung CL, et al; SAPS 3 investigators SAPS 3 investigators End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med. 2009;354:623-630. [CrossRef] [PubMed]
 
Sprung CL, Maia P, Bulow H-H, et al; Ethicus Study Group Ethicus Study Group The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;3310:1732-1739. [CrossRef] [PubMed]
 
White DB, Evans LR, Bautista CA, Luce JM, Lo B. Are physicians’ recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med. 2009;1804:320-325. [CrossRef] [PubMed]
 
Shafer TJ, Wagner D, Chessare J, et al. US organ donation breakthrough collaborative increases organ donation. Crit Care Nurs Q. 2008;313:190-210. [PubMed]
 
Luskin RS, Glazier AK, Delmonico FL. Organ donation and dual advocacy. N Engl J Med. 2008;35812:1297-1298. [CrossRef] [PubMed]
 
Iltis AS, Rie MA, Wall A. Organ donation, patients’ rights, and medical responsibilities at the end of life. Crit Care Med. 2009;371:310-315. [CrossRef] [PubMed]
 
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