Here is a little 'thought experiment' which can be transferred to decision-making during healthcare
Here is a little 'thought experiment' which can be transferred to decision-making during healthcare.
Suppose that there is an airliner, which is flying to a holiday destination. The pilots and the engineers, are the experts in whether the aircraft is airworthy, and for how to actually fly the aircraft to the destination. There will be passengers on the aircraft, if the fare is reasonable and if people want to go to the destination.
Now, suppose that there is a smaller chartered aircraft, flying from the same airport, which is akin to a flying taxi: a customer hires the aircraft to fly him, or her and her friends, to a stated destination.
The expertise needed to fly the aircraft, and to check the aircraft is airworthy, is different from the decision the passengers make about where to fly to, and whether to fly at all. In particular, if someone charters an aircraft to fly him and his friends to a holiday destination every year, and every year the customer uses a different charter company, the charter company could only guess at where the aircraft would be flying to, based on where customers tend to fly to, before the customer has told them the destination - but the friends who regularly go on holiday with the chap who books the aircraft would be better able to guess at a likely destination, based on their previous holidays together.
If we transfer this to healthcare, then things such as 'what a surgeon decides to do next during a surgical operation' equates to the 'knowing how to fly the aircraft' bit. The 'understanding what the patient would be likely to decide if he cannot tell you himself' requirement within healthcare when the patient lacks mental capacity, equates to 'guessing where the charter destination will be' - and 'the friends who regularly go on holiday with the chap' equates to 'the close family and friends of the patient'.
And of course, the autonomy of a capacitous patient, is represented by whether or not passengers decide to pay for seats on the scheduled airliner, and where the chap who charters an aircraft decides it will fly to.
For some reason, these very obvious concepts seem to become muddled, blurred and mis-described when people write about healthcare: being qualified in clinical techniques and skills is incorrectly assumed to equip clinicians to make best-interests decisions, when in reality is it 'knowing the patient as a 'close friend'' that best equips a person to make a best-interests decision, and decisions about whether to accept or decline an offered treatment which are being made by a patient are typically described as 'shared decisions, made by the patient and his clinicians' when in fact the decision is no more shared than whether passengers book seats on the scheduled airliner, or where the chap who charters an aircraft decides it will fly to.
Does that make sense ? Is it easy to follow ?
Hi Mike,
I understand your analogy in the sense of its being a clarification tool, however, there is an ethical dimension to the circumstances of healthcare that does not appertain to matters of aviation. While clinicians may not 'know' the inner-most wishes of the patient neither do they come under the sway of potentially misguided or ulterior motives. Dilemmas, dilemmas .....
I don't think aviation and best interests of somebody are in the same bracket here.
A pilot can always change course, and go to a different destination. He is reading maps.
With healthcare its about people. ITs about what you're putting into their lives. Sometimes it's almost as if it's raising a child. You put everything into it. Your thoughts, finances, ideas, time, defence mechanisms, even party events. When medical decisions have to be made for parents, this is very traumatic. It's no different when the roles are reversed and decisions have to be made FOR that parent.
Hi Suzie,
I quite like 'clarification tool'.
Medics invariably introduce ethics - I invariably want to start from the law, and then to apply a combination of logic and perspective-balance to whatever remains legally unclear.
I explained my objections in my BMJ rapid response titled 'Michael H Stone: A defence of my preference for law and not ethics' at:
http://www.bmj.com/content/353/bmj.i2230/rr-7
What follows is extracted from the piece, and it explains, I hope, why I dislike 'ethics':
The reason I am so keen on people sticking to the informed consent described in our English law, is not that I am 'against happy endings', nor am I sanguine about young adults, 'exercising their legal right to kill themselves'. I am so insistent about the application of informed consent, because I became involved not in a general 'ethical debate', but in a debate about end-of-life behaviour. And the ethics which many professionals seem to apply during end-of-life, offend me. I am offended that most guidance seems to imply that if a terminal patient has clearly expressed a refusal of a future treatment to a member of his family, 'somehow this counts less than if he had expressed it to a GP'. I am offended that even if I write a very clearly worded Advance Decision refusing cardiopulmonary resuscitation irrespective of why I arrest, if I arrest at home and the death could not be certified, attending 999 paramedics would be likely to ignore my instruction and would probably attempt CPR. I am offended that for known end-of-life but not yet 'expected' home deaths, the police tend to become involved, and to treat the family as if they are suspects - but I feel sure that deaths which happen in identical clinical situations, but in hospital, do not result in the police attending and interrogating the nursing staff. These things all offend me, and they also 'offend my ethics'. My ethics include things such as 'no accusation without some evidence': people should be assumed honest until proven otherwise; decent end-of-life support for patients requires that clinicians and family carers should be working together; etc. So my ethics, appear to be different from the 'ethics' of 999 paramedics, police officers, etc.