Abstract
Western, specifically American, medical ethicists, in a reaction against a particular narrative of medical paternalism, have called for the use of a shared decision making process. Increasingly, this process is primarily aimed at honoring the autonomy of the patient. However, the concept of autonomy invoked often assumes an isolated, idealistic, individual deciding amongst neutral options from an objective position free from all biases. However, such an individual original position is fictional. American physicians, complicit in this false assumption, have been reduced to providers of options instead of givers of guidance. This paper describes a better path to achieve a shared decision that respects and serves patients. It urges physicians to employ an appropriate degree of directiveness. Further, it argues that one may enhance the true autonomy of patients by engaging their rich contextual influences and biases. This will include communal decisions, decisions that include the family or other significant community. The common experience of communal decision making amongst certain families and religious communities in the United States are positive examples. Using the frame of end-of-life care decisions, including considerations of decision burden and bereavement, the superiority of family or community oriented decision-making is explored with arguments of inherent value and positive potential consequences.
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Notes
- 1.
- 2.
Wealth can have many different measures such as money, goods, property, and even social considerations. Wealth is often relative to the given time of consideration. Thus many poor of today have necessities of life that poor of previous generations lacked. However, beyond the material it is arguable that in many ways modern cultures are impoverished socially, culturally, and religiously.
- 3.
- 4.
This theme is repeated throughout Bishop 2011.
- 5.
See: Juvin 2010, p. 158. It should be pointed out that pleasure in my treatment, consistent with Juvin’s, is referring to an immanent self-serving gratification that focuses on immediacy.
- 6.
Pleasure is potentially a complex topic that this paper will not explore in great detail. For the purposes of this paper pleasure is to be defined as temporal pleasure that serves the self in tangible ways. In contrast, it is not referencing the gratification of an altruistic act, the joy of deep intimacy, or wonder of eschatological joy.
- 7.
See: Juvin 2010, p. 38, 175.
- 8.
See: Vlachos 1999, p. 16.
- 9.
See: Engelhardt 1996, p. 123.
- 10.
- 11.
Decisional capacity evaluations are done by a host of other healthcare team members as well, such as psychologists, counselors, social workers, nurses, chaplains, etc.
- 12.
See: Dupre 1993.
- 13.
See: Barzun 2000.
- 14.
See: Kerr 1997, p. 3.
- 15.
See: Murray 2012, pp. 149–167.
- 16.
See: Bishop 2011, p. 60.
- 17.
These techniques may include various methods of subtle persuasion from healthcare team members such as bioethicists, psychologists, chaplains, physicians, social workers, case managers, or business officers.
- 18.
See: James 1911, pp. 127–152.
- 19.
See: Dewey 1935.
- 20.
Contemporary bioethics often recognizes that some cultures and religions desire family oriented or community decision making yet no real concession is made to allow such. Beauchamp and Childress (2009, pp. 106–107) suggest that the practical way to deal with those requesting family-oriented consent is to ask the individual if this is his preference. This, of course, is the application of an individualistic system and already does violence to any family-oriented consent.
- 21.
See: Engelhardt 1996, pp. 6–9.
- 22.
- 23.
These terms, particularly persuasion, manipulation, and coercion, have been considered by various authors, including Ruth Faden and Tom L. Beauchamp (1986). These sources often focus on the perspective of the patient and their mind. The current treatment is focusing on the intent of and style employed by the physician.
- 24.
As previously mentioned these may include clinical ethicists, psychiatrists, counselors, social workers, nurses, or chaplains that have the duty in ‘decision support.’
- 25.
See Chen and Fan 2010.
- 26.
Vlachos 1999, p. 117.
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Nash, R. (2015). Toward a Shared Decision: Against the Fiction of the Autonomous Individual. In: Fan, R. (eds) Family-Oriented Informed Consent. Philosophy and Medicine(), vol 121. Springer, Cham. https://doi.org/10.1007/978-3-319-12120-8_14
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