Ethical issues / Éthique et déontologie

Bioethics for clinicians: 4. Voluntariness

Edward Etchells, MD, MSc, FRCPC; Gilbert Sharpe, BA, LLB, LLM; Mary Jane Dykeman, LLB; Eric M. Meslin, PhD; Peter A. Singer, MD, MPH, FRCPC


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Canadian Medical Association Journal 1996; 155: 1083-1086

[résumé]

Drs. Etchells and Singer are from the Department of Medicine, University of Toronto, The Toronto Hospital and the University of Toronto Joint Centre for Bioethics, Toronto, Ont. Mr. Sharpe is a professor in the Faculty of Health Sciences, McMaster University, Hamilton, Ont., and is director of the Legal Services Branch, Ontario Ministry of Health, Toronto, Ont. At the time of writing, Ms. Dykeman was completing her articles at the Legal Services Branch, Ontario Ministry of Health, Toronto, Ont. Dr. Meslin is with the University of Toronto Joint Centre for Bioethics, University of Toronto, Toronto, Ont., and the Clinical Ethics Centre, Sunnybrook Health Science Centre, North York, Ont.

Dr. Singer's work is supported by the National Health Research and Development Program through a National Health Research Scholar award. The views expressed here are the authors' and not necessarily those of their supporting groups or employers.

This 14-part series on bioethics for clinicians began in the July 15, 1996, issue. Subsequent articles will appear monthly.
Paper reprints may be obtained from: Dr. Edward Etchells, Division of General Internal Medicine, The Toronto Hospital, Rm. EN G-248, 200 Elizabeth St., Toronto ON M5G 2C4; eetchells@torhosp.toronto.on.ca

Series editor: Dr. Peter A. Singer, University of Toronto Joint Centre for Bioethics, 88 College St., Toronto ON M5G 1L4; fax 416 978-1911; peter.singer@utoronto.ca

© 1996 Canadian Medical Association (text and abstract/résumé)

Abstract

In the context of consent, "voluntariness" refers to a patient's right to make health care choices free of any undue influence. However, a patient's freedom to make choices can be compromised by internal factors such as pain and by external factors such as force, coercion and manipulation. In exceptional circumstances -- for example, involuntary admission to hospital -- patients may be denied their freedom of choice; in such circumstances the least restrictive means possible of managing the patient should always be preferred. Clinicians can minimize the impact of controlling factors on patients' decisions by promoting awareness of available choices, inviting questions and ensuring that decisions are based on an adequate, unbiased disclosure of the relevant information.

Résumé

 Dans le contexte du consentement, on entend par «volontarisme» le droit du patient de faire, à l'égard des soins de santé, des choix libres de toute influence indue. Des facteurs internes comme la douleur et des facteurs externes comme la force, la coercition et la manipulation, peuvent toutefois compromettre la liberté de faire des choix d'un patient. Dans des circonstances exceptionnelles -- comme une hospitalisation involontaire, par exemple -- les patients peuvent perdre leur liberté de choix. Il faut alors toujours privilégier les moyens les moins restrictifs possibles pour traiter le patient. Les cliniciens peuvent réduire au minimum l'incidence des facteurs de contrôle sur les décisions des patients en favorisant la sensibilisation aux choix possibles, en incitant les patients à poser des questions et en veillant à ce que les décisions soient fondées sur une divulgation suffisante et impartiale des renseignements pertinents.

Mrs. K, who is 85 years old, was born in Germany but is fluent in English. She lives alone and carries out most activities of daily living independently. One day she collapses on her way to the grocery store. She is taken to hospital, where a large subarachnoid hemorrhage is diagnosed. She is comatose for 3 days. When she awakes on the third night she appears extremely confused and speaks only in German. She repeatedly climbs out of bed and pulls at her bladder catheter. The surgeon wonders if she should be physically restrained.

Mr. L is 65 years old and has been admitted to hospital with severe iron-deficiency anemia. After his condition is stabilized by means of a blood transfusion, an endoscopy is ordered. The attending physician tells Mr. L that he will "have a test" because "he must be bleeding from the bowel." He adds, "I want you to have this test before you go home." Mr. L, dressed in a hospital gown, is lying on a stretcher in the hallway outside the endoscopy suite when the endoscopist arrives.

Mr. M is 90 years old and lives with his wife in a senior's apartment. He is independent in most activities of daily living. He is admitted to hospital with acute myocardial infarction complicated by mild congestive heart failure. The emergency physician discusses advanced cardiac life support (cardiopulmonary resuscitation [CPR], and electrical cardioversion and defibrillation). During the discussion, the clinician emphasizes that CPR causes broken ribs and, even when successful, leaves the patient with severe neurologic impairment. Mr. M declines CPR and is consequently admitted to a ward bed without continuous cardiac monitoring.

What is voluntariness?

In the context of consent, "voluntariness" refers to a patient's right to make treatment decisions free of any undue influence. A patient's freedom to decide can be impinged upon by internal factors arising from the patient or the patient's condition or by external factors. External factors, which are the focus of this article, include the ability of others to exert control over a patient by force, coercion or manipulation.[1] Force involves the use of physical restraint or sedation to enable a treatment to be given. Coercion involves the use of explicit or implicit threats to ensure that a treatment is accepted (e.g., "If you don't let us do these tests, then we will discharge you from the hospital!"). Manipulation involves the deliberate distortion or omission of information in an attempt to induce the patient to accept a treatment.[2,3] Mr. M is a manipulated patient: no reasonable person would consent to CPR if he or she believed that it always resulted in pain and severe brain damage, with no hope of any benefit.

The requirement for voluntariness does not imply that clinicians should refrain from persuading patients to accept advice. Persuasion involves appealing to the patient's reason in an attempt to convince him or her of the merits of a recommendation.4 In attempting to persuade the patient to follow a particular course of action, the clinician still leaves the patient free to accept or reject this advice.

Why is voluntariness important?

Ethics

Voluntariness is an ethical requirement of valid consent. It is grounded in several related concepts, including freedom, autonomy and independence.[5] The goal of the consent process is to maximize the opportunity for decisions to be reached autonomously.[6] Practically, it requires the physician to ensure that situations do not arise in which the patient's actions are substantially controlled by others. There is an inherent power imbalance in the physician­patient relationship; clinicians should strive to minimize this imbalance by fostering autonomous decision-making by their patients. (The concept of "consent" is discussed in the first article in this series.[7])

Law

Voluntariness is a legal requirement of valid consent. In Beausoleil v. Sisters of Charity[8] a young woman about to undergo spinal surgery repeatedly requested a general anesthetic and refused a spinal anesthetic. After the patient had been sedated, the anesthetist convinced her to have a spinal anesthetic. The patient was subsequently paralyzed as a result of the procedure and successfully sued the anesthetist. In testimony, a witness said that the patient "refused [the spinal anesthetic], but they continued to offer it to her; finally she became tired and said: 'You do as you wish' or something like that."[9] The judge stated that the patient's agreement to the spinal anesthetic was involuntary, because it rested on "words which denote defeat, exhaustion, and abandonment of the will power."[9]

In Ferguson v. Hamilton Civic Hospitals et al,[10] a patient unsuccessfully sued for battery after undergoing an angiogram that resulted in quadriplegia. Although the suit was unsuccessful, the court was critical of the circumstances in which the consent was obtained and suggested that "the informing of a patient should occur at an earlier time than when he is on the table immediately before undergoing the procedure."[11] It has been suggested that obtaining consent just before a major procedure is problematic, because "the setting and the immediacy of the medical procedure militate against a patient being able to make a free or voluntary decision."[12]

Some legislation allows for treatment to be given in certain circumstances without the patient's volition. For example, irresponsible people with communicable diseases may be treated against their objection, as in the case of patients with tuberculosis who are noncompliant with treatment. Also, all provinces allow for the involuntary admission of patients to psychiatric facilities, provided they present an immediate risk to themselves or others, or are unable to take care of themselves. However, in most provinces, a patient who is admitted involuntarily may not be treated without consent except in emergency situations in which the patient is incapable. (Patient "capacity" is discussed in the third article in this series.[13]) Because of the coercive nature of such circumstances, extra care should be taken in obtaining consent from patients who have been admitted involuntarily.

Policy

Voluntariness is an essential component of valid consent, and obtaining valid consent is a policy of the CMA[14] and other professional bodies.

Empirical studies

Psychiatric inpatients may be subject to explicit or implicit coercion even when their admission has been voluntary.[15­17] However, even patients who require involuntary admission can be given some measure of control over their situation by being allowed to choose the method of restraint.[18]

Institutionalization in nonpsychiatric hospitals or long-term care facilities can also be coercive. Even simple instructions to patients (e.g., "Don't get out of bed until after your breakfast") can give the patient a sense of diminished control.[19] Interventions that enhance the ability of long-term residents to exert control result in a greater sense of well-being,[20] and many long-term care facilities have developed successful programs to reduce the use of restraints.[21]

Outpatients are less likely than inpatients to be subjected to force and coercion,[22] but they may be susceptible to manipulation. Although we are unaware of any data on the incidence of manipulation, many studies indicate that decisions can easily by influenced by the manner in which information is presented.[23­26] It is possible for such manipulation to occur in clinical practice.

How should I approach voluntariness in practice?

Internal and external controlling factors can affect patients' decisions about treatment (Fig.1). For example, a patient with metastatic prostate cancer and bone pain is subject to internal controlling factors. A symptom-free life without treatment is not possible, and the patient must make some decisions while suffering severe pain, at least until the pain is treated. These internal factors arise from the patient's medical condition rather than from an external source, such as any action by the clinician. The clinician's role is to minimize the potential controlling effect of these internal factors. For example, the clinician can reduce the impact of acute pain on decision-making by deferring nonurgent decisions until the pain has been treated.

External controlling factors may be related to the clinician, the health care setting or to other people such as family and friends. We will focus here on the clinician and the health care setting; the problems that can arise when family, friends or others exert excessive control are beyond the scope of this article.

In the few circumstances in which it is acceptable for clinicians to use force, the least restrictive technique possible should be preferred. For example, if a patient is at immediate risk of harming himself or herself, simple observation in a supervised environment, rather than physical restraint or sedation, may be sufficient. Similarly, an elderly patient with delirium who is falling out of bed can be moved to a mattress on the floor so that the risk of falling is eliminated without physical restraint.

In psychiatric and long-term care institutions a patient advocate can help the clinician ensure that consent is not coerced.[27] Clinicians can also take steps to minimize the coercive nature of institutions by enhancing the patient's sense of choice. Useful strategies might include encouraging patients to involve their family in decisions, encouraging them to ask questions and promoting their awareness of the choices available to them (e.g., "I would like you to have a test tomorrow. Do you want to talk about it with your family? Is there any reason to delay?").

Clinicians can also take steps to minimize the potential for manipulation. First, because patients can be manipulated when the information they receive is incomplete, clinicians should ensure that adequate information has been disclosed to the patient. (The requirements for adequate disclosure are discussed in the second article in this series.[28]) Second, manipulation can occur when information is presented in a biased fashion. A useful strategy is to ask patients to review information in their own words. Also, if a patient who accepts therapy because of its potential benefits continues to accept it when its potential risks are emphasized, then the clinician can be more confident that this decision has not been manipulated.[29]

The cases

The surgeon tries to determine why Mrs. K is climbing out of bed. A German-speaking relative is contacted; she ascertains that Mrs. K is disoriented but is also very worried about her cat at home, who needs to be fed. The relative reassures Mrs. K that a neighbour has been feeding the cat. Mrs. K is visibly relieved and becomes less agitated. The surgeon decides that Mrs. K can be monitored safely without the bladder catheter, and the catheter is removed. The relative agrees to stay overnight to ensure that Mrs. K does not fall out of bed. Mrs. K is not restrained.

The endoscopist asks Mr. L to review the reasons for the test in his own words. Mr. L says that he's got "no choice but to have the test" because "my doctor needs it done before I go home." Because the endoscopy is not an emergency, the endoscopist calls the attending physician, who agrees that the test should be delayed. After a further discussion that afternoon, Mr. L consents to the endoscopy, which is performed the next morning.

On the medical ward, Mr. M's attending physician asks why he has refused advanced cardiac life support. Mr. M explains that if his heart stopped then he would "rather be dead than a vegetable with broken ribs." He adds that he hopes to be alive and able to attend his granddaughter's wedding next month. The clinician discusses the potential benefit of defibrillation in the event of a witnessed cardiac arrest related to acute myocardial infarction. Despite the potential benefits of CPR, Mr. M says he would prefer to forego the treatment, because "I've lived a good life and I'm ready to go." He remains on the medical ward, recovers and attends his granddaughter's wedding.

References

  1. Faden RR, Beauchamp TL. A history and theory of informed consent. New York: Oxford University Press, 1986: 259.
  2. Pendleton DA, Bochner S. The communication of medical information in general practice consultations as a function of patients' social class. Soc Sci Med 1980; 14A: 669-73.
  3. Shapiro MC, Najman JM, Chang A, Keeping JD, Morrison J, Western JS. Information control and the exercise of power in the obstetrical encounter. Soc Sci Med 1983; 17: 139-46.
  4. Faden RR, Beauchamp TL. A history and theory of informed consent. New York: Oxford University Press, 1986: 261-2.
  5. Faden RR, Beauchamp TL. A history and theory of informed consent. New York: Oxford University Press, 1986: 256-7.
  6. Faden RR, Beauchamp TL. A history and theory of informed consent. New York: Oxford University Press, 1986: 239.
  7. Etchells E, Sharpe G, Walsh P, Williams JR, Singer PA. Bioethics for clinicians: 1. Consent. Can Med Assoc J 1996; 155: 177-80.
  8. Beausoleil v. Sisters of Charity (1966), 56 DLR 65 (Que CA).
  9. Beausoleil v. Sisters of Charity (1966), 56 DLR 65 (Que CA), note 7 at 76.
  10. Ferguson v. Hamilton Civic Hospitals et al, 23 CCLT 254.
  11. Ferguson v. Hamilton Civic Hospitals et al, 23 CCLT, note 10 at 285.
  12. Picard E. Legal liability of doctors and hospitals in Canada. 2d ed. Toronto: Carswell, 1984: 55.
  13. Etchells E, Sharpe G, Elliott C, Singer PA. Bioethics for clinicians: 3. Capacity. CMAJ 1996; 155: 657-61.
  14. Canadian Medical Association. Informed decision-making [policy summary]. CMAJ 1986; 135: 1208A.
  15. Reed SC, Lewis DA. The negotiation of involuntary admission in Chicago's state mental hospitals. J Psychiatr Law 1990; 18 (spring/summer): 137-63.
  16. Kinzie JD, Holmes JL, Arent J. Patients' release of medical records. Involuntary, uninformed consent? Hosp Community Psychiatry 1985; 36: 843-7.
  17. Rogers A: Coercion and "voluntary" admission: an examination of psychiatric patient views. Behav Sci Law 1993; 11: 259-67.
  18. Sheline Y, Nelson T. Patient choice: deciding between psychotropic medication and physical restraints in an emergency. Bull Am Acad Psychiatry Law 1993; 21: 321-9.
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  20. Langer EJ, Rodin J. The effects of choice and enhanced personal responsibility for the aged: a field experiment in an institutional setting. J Pers Soc Psychol 1976; 34: 191-8.
  21. Miles SH, Meyers R. Untying the elderly: 1989 to 1993 update. Clin Geriatr Med 1994; 10: 513-25.
  22. Connelly JE, Campbell C. Patients who refuse treatment in medical offices. Arch Intern Med 1987; 47: 1829-33.
  23. Mazur DJ, Hickam DH. The effect of physicians' explanations on patients' treatment preferences. Med Decis Making 1994; 14: 255-8.
  24. Brun W, Teigen KH. Verbal probabilities: Ambiguous, context-dependent, or both? Organ Behav Hum Decis Process 1988; 41: 390-404.
  25. Pepper S, Prytulak LS. Sometimes frequently means seldom: context effects in the interpretation of quantitative expressions. J Res Pers 1974; 8: 95-101.
  26. Sutherland HJ, Lockwood GA, Tritchler DL, Sem F, Brooks L, Till JE. Communicating probabilistic information to cancer patients: Is there "noise" on the line? Soc Sci Med 1991; 32: 725-31.
  27. Review of Advocacy for Vulnerable Persons. You've got a friend: a review of advocacy in Ontario [report]. Toronto: Ontario Ministry of the Attorney General, 1987: 52-8.
  28. Etchells E, Sharpe G, Burgess MM, Singer PA. Bioethics for clinicians: 2. Disclosure. Can Med Assoc J 1996; 155: 387-91.
  29. Redelmeier PA, Rozin P, Kahneman D. Understanding patients' decisions: cognitive and emotional perspectives. JAMA 1993; 270: 72-6.
| CMAJ October 15, 1996 (vol 155, no 8)  /  JAMC le 15 octobre 1996 (vol 155, no 8) |
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