Autonomy, Capacity and Dignified Death Essay

Summary: The Council of Europe protects the right of people in terminal phase or dying, to self-determination. But only if the patient is competent, you can make independent decisions about their health. The capacity will be assessed by doctors to consider as valid informed consent.Autonomy, Capacity and Dignified Death Essay

The doctor-patient relationship, nowadays, follows the clinical method “focused on the patient” where the physician has a double task, understand the patient and understand the disease, in this context are key exploring the experience of illness, shared decision making and the search for agreements to which the patient is able to take responsibility for their own salud1. In this manner, it could be considered the patient medical encounter as a meeting of experts, Doctors are experts in medical science and patients are experts in their lives. And this is because modern ethics has transformed the maximum standard Hippocratic “aegroti salud suprema lex” in “aegroti voluntas suprema lex”, that is, now is not the health of the sick the supreme law because it is his will (Sass)2. The emergence of the value of personal autonomy has profoundly changed the values of the clinical setting, it must now adapt to the individuality of the sick person. In a democratic society, respect for the freedom and autonomy of the person must be kept during the illness and fully achieve the process of death3. Ten years ago, on October 19, 2005, the General Conference of UNESCO adopted the Universal Declaration on Bioethics and Human Rights4, which states, in Article 5, it must respect the autonomy of the individual in relation to the power to make decisions. The exercise of this right leads us to define and protect the ideal of a dignified death, and that is if all human beings aspire to live with dignity, die with dignity is also part of a dignified life. Among the fundamental contents of the ideal of “death with dignity” that enjoy consensus, is the right of patients to receive comprehensive high-quality palliative care. Recommendation 1418/1999 of the Parliamentary Assembly of the Council of Europe, 5 “Protection of human rights and dignity of the terminally ill and dying” in Article 9, paragraph B, protects the right of the terminally ill or dying to self-determination, and also recommends taking steps to ensure that health decision, which elects the patient or their family may be respected, including the rejection of a specific treatment measures. It also recognizes that a death wish of a terminally ill or dying person cannot in itself constitute a legal justification for actions to end his life. In Spain is not authorized euthanasia or assisted suicide and other actions are considered good practice to record the living will to make decisions about the refusal of treatment, the limitation of life support and palliative sedation. With this in mind, we asked if a sick person is able to make a decision about their health, sick people are able to make that decision and at that particular moment? If we believe in informed consent as an ongoing process, communicative, dialogic (spoken), deliberative and conservative, we need a patient with capacity made (competition) to make decisions about the nature of his illness, the effects of it and the risks and benefits of diagnostic and therapeutic procedures, requesting approval to undergo any them6. Autonomy, Capacity and Dignified Death Essay Thus the purpose of informed consent is obtained; We talk about guaranteeing the rights of patients, empower, protect the patient from unwanted treatment and help you make the right decisions about health care, so that they are correlated with their personal values. The capacity to which we refer is the competition that the doctor can and should evaluate in the clinical practice and is what we call “capacity of made or natural”7. It is a psychological and clinical concept, defining the psychological skills needed to take, here and now, a certain decisión8. Only if the patient is competent, you can make independent decisions about their health9, therefore, assess the ability of the patient is in fact a fundamental requirement in the process of informed consent. Capacity is the ability of the person to understand the situation it faces, the values that are at stake, the possible courses of actions and expected consequences for, then take express and defend a decision that is consistent with their own values. It varies over time, if mental status changes, also capacity10. The Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the application of biology and medicine, the Council of Europe, commonly called the Oviedo Convention, in force since 1 January 200011, in articles 6, 7, 17 and 20 deal with the problem of lack of capacity to consent freely. Thus, the most important ethical argument of the obligation to assess the competence or ability of a patient is the principle of nonmaleficence, for those actions that may cause physical or moral harm to persons should be avoided. And so maleficent will allow the patient natural inability to take decisions, which can cause health damage, such as preventing the patient able to exercise its autonomy to decide. There is also the obligation of beneficence, optimize the participation of the incompetent patient in decision-making, by all possible means, to reverse, if possible, your disability, or provide information so that you can participate in the decision the extent possible9. Evaluating and determining the ability to make a medical decision a patient is a task that involves an enormous ethical and legal responsibility. Codes of ethics widely collected an ethical obligation to professionals for consider the patient’s competence. Historically, the doctors has enjoyed considerable social recognition, for determine the capacity. However, the use of standardized tools for assessment of competence is vital, given that informal evaluations by doctors depend on the idiosyncrasies of each and therefore would be little fiables12. This is the same problem that arose in the United States in the late seventies, when American physicians began systematically applied in clinical practice informed consent. After more than thirty years in this line, it is considered what the best tool available, in health care, for the assessment of the ability to make medical decisions is the Aid to capacity evaluation (ACE)13. Its literal translation would help to assess capacity. Understood the term capacity, from the perspective of bioethics, as a synonym for competence in decision-making. For this, the ACE evaluates the understanding of information, and the ability of the patient to say and communicate a particular medical decision. The ACE is validated in the initial work of Etchells et al, in adult patients who needed to make an informed consent treatments or diagnostic procedures, such as endoscopies performing, transfusion, etc. The ACE evaluates recognition the disorder of convivence and the understanding of informed consent (Etchells at al., 1999)14. It was developed in Ontario, Canada, where these two standards are relevant to the current legislation. Recently, it has been adapted and validated to Spanish (Moraleda et al15), both diagnostic and treatment processes to make decisions about their disease. The ACE is a semi-structured interview assessment that addresses seven facets of the capacity for real and concrete medical decision assesses the ability to understand (1) the medical condition, (2) treatment, (3) and treatment alternatives (4) the option of refusing treatment; the ability to perceive the consequences of (5) to accept treatment and (6) deny treatment; and (7) the possibility that the patient is in a context of hallucinations, delusions or depression, which can significantly interfere in their decision making. The questions in the first four areas assessed the capacity of understanding. Questions 5 and 6 explore the reasoning. And in the seventh area of mental pathology situations which clearly affect the ability clarified. See Table 1. This tool is considered highly reliable and has a sensitivity of 81% and a specificity of 90%, comparing the judgment of expert medical interview conducted with ACE. Some of the advantages of ACE are its realization in a short time and that is adapted to the clinical case and the specific treatment of each patient.Autonomy, Capacity and Dignified Death Essay

The health professional provides all the information as possible to the patient, and values its ability asking open-ended questions about the decision to take, alternatives, possible consequences, and the possibility of rejecting the offer option. Scores are not added together, to interview the patient about his decision, aspects of understanding of information and the ability of the patient to decide and communicate a particular medical decision are evaluated. This type of semi-structured interview requires a basic training by the professional and helps to classify the patient into one of the following four categories: capable, probably capable, probably incapable or incompetent. And in turn, these four results are divided into two: the incapable of making that decision would be unable and the others are capable. The cut is made according to the criteria of patient autonomy. The principle of respect for persons, of Kantian origin, is based on the dignity of the person, is its moral autonomy, and therefore freedom. It requires that every human being are regarded autonomous and free, imposing respect for their dignity and self determination. Therefore they must be respected their decisions if a person is able, competent and adequately informed. And likewise, this principle requires the development of legal mechanisms for the protection of individuals where these attributes were limited, as in the case of patients classified as permanently incapable. Traditionally, the principle of autonomy is expressed in all its value, it must be considered that an autonomous action must meet three conditions: intent, knowledge and absence of external control. Diego Gracia16 added a fourth condition: authenticity. If an act is intentional, if it has been made with full understanding and without control or external undue influence, but is not consistent with the value system and attitude toward life, typical of who performs it, is not an authentic act, and therefore, it is not truly autonomous. The interview with the ACE is a very useful tool, but to doubtful cases or more complex decisions are recommended to complete the interview with other evaluation measures that will help us reduce uncertainty in determining the ability of a patient to a medical decision. In case of incapacity consent is granted of representation. It is considered that an individual is unable if it is not able to make a particular decision at a particular time, at the discretion of the physician responsible for the care, or physical or mental condition and does not allow him to take charge of their situation. Moreover, it is considered that a patient is disabled when a judge has determined this, as stated in Article 199 of the Civil Code, in Spain. And in the case of minors, the consent of the representation will be required when the minor patient (over 12 or 16 years, depending on the decision and under 18 years of age), it is not intellectually or emotionally capable of understand the scope. With minors, the mission is to demonstrate the maturity, unlike what happens with adults. With the adults is necessary evaluate the clinical disability as it is supposed to be able. Diego Gracia17 recommended that the assessment of mental capacity must be reasonable and reasoned, assessing the circumstances, previous medical history, current psychopathological assessment, family and social support, patient values, and the foreseeable consequences of the decision to take. In certain cases it may be useful the use of a semi-structured interview (ACE) to review the decision-making skills. In case of failure, the use of deliberative method can be helpful to assess each case.Autonomy, Capacity and Dignified Death Essay

Determining the ability of fact (capacity), before taking a decision, in the processes of decision making, it is a habit that all doctor should include in their daily work, is an improvement in the organization and management of resources because it means improving the principles of bioethics with our most fragile patients.

As medical techniques have increased in complexity, death can be delayed more and
more, and the debate over euthanasia has become increasingly important. Patients with chronic
ailments such as AIDS or cancer can now receive treatments that allow them to survive for far
longer than what was possible even only a few decades ago. Through the use of modern genetic
analysis tools, companies like 23andMe have allowed people of all ages to know what diseases
and infirmities they are prone to long before the onset of symptoms. Despite these advancements
however, society’s definition of “survive” remains purely having the body’s mechanical
processes continue, and fails to incorporate the patient’s suffering and quality of life into the
discussion. Due to the intrinsically subjective nature of such complaints from a patient, the
critical factor to be considered in the ethics of requests to die will be how the patient views their
suffering and quality of life, not the observations of third parties. In this essay I will argue that if
a patient makes a considered request to die rather than suffer prolonged physical or mental
agony, then those who have the capability to do so should honor that request. I further argue that
such an action is entirely morally justifiable. For the purposes of this essay I will use euthanasia
to mean “directly or indirectly bringing about the death of another person for that person’s sake,”
with passive euthanasia being synonymous with “letting die” and active euthanasia involving a
direct action.Autonomy, Capacity and Dignified Death Essay
When using the term ‘suffer’ most people understand what is meant, but when pressed
can only present examples from their own lives with complete certainty. With respect to the loss
of a loved one, for example, it is generally agreed that ‘everyone mourns differently,’ in that

1
Vaughn, L. (2013). Bioethics: Principles, issues, and cases. (2nd ed., pp. 594-609). New York: Oxford
University Press.
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Published by Sound Ideas, 2015
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some people may outwardly show no change but internally be dealing with the complex
emotions such an event can bring up. It can be extremely challenging to guess exactly what
anyone is feeling at a given time, and impossible to definitively ‘know’ even if the person
attempts to relay his or her feelings to you. In addition, for the person suffering there is little
difference between mental anguish and physical agony. To the sufferer, severe depression is just
as real as a broken arm, despite the heavy societal emphasis placed upon physical suffering.
Because pain can be physical or mental, or both, and to the sufferer the origin of that pain can be
irrelevant, it is remiss not to consider prolonged mental anguish as an equally valid reason to ask
for euthanasia as physical pain is.
The obvious fear here is that people with mental disorders that cause them to ‘feel’
emotions more (e.g. bipolar disorder, depression, etc.), and hormone-filled teenagers will, in a
flight of dramatic passion, plead to be freed from the trauma and tragedies of life. It is tempting
for outside observers to refuse such a request because we ‘know’ it gets better. As described
earlier however, it is not possible for anyone to definitively know that, as the best such observers
can truly do is compare the sufferer’s current situation to something that they lived through. This
does not mean that these observers have any idea of the level of suffering another person can
bear or that they have a right to force the victim to live through to the better days the patient may
fail to see. As bioethicist John Lachs explains, “It would indeed be tragic if medicine were to
leap to the aid of lovelorn teenagers whenever they feel life is too much to bear. But it is just as
lamentable to stand idly by and watch unwanted lives fill up with unproductive pain.2
” Such a
premise is applicable to any demographic group suffering mental anguish. It is often more
palatable to discuss physical suffering in regards to euthanasia as a treatment for persistent pain,

2 Lachs, J. (1994). When abstract moralizing runs amok. In L. Vaughn (Ed.), Bioethics: Principles,
issues, and cases (2nd ed., pp. 630-634). New York: Oxford University Press.Autonomy, Capacity and Dignified Death Essay
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Sound Decisions: An Undergraduate Bioethics Journal, Vol. 1 [2015], Iss. 1, Art. 2
https://soundideas.pugetsound.edu/sounddecisions/vol1/iss1/2
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so subsequent examples in this essay will revolve around the corporeal, but it should not be
forgotten that mental and physical anguish are often interchangeable when viewed from the
perspective of the sufferer.
There are many factors that are called into question when considering the validity of a
request for euthanasia, and several of these fail to account for the goal of such an act: to end
prolonged suffering. Typically the age of the patient is associated with the validity of a request
for euthanasia because of a misinterpreted link between age and experience. This inequity only
becomes clear in practice. In the abstract, one might well agree with bioethicist Lewis Vaughn
that in the case of a terminal patient “if her pain is unbearable and untreatable, and she makes an
autonomous request to die, then active euthanasia may be a blessing—and therefore within
ethical bounds,” regardless of who “she” is in this case.3
However, in practical examples,
distinctions are made often based solely on age. Consider an 80-year-old person suffering from
cancer who tells a doctor that his suffering is too great and asks for euthanasia to end the agony.
If it were legal, such as in Oregon and Washington, the state would likely respect this request as
legitimate, leaving aside the responsibility of the doctor for the moment. On the other hand,
consider a child of 10 who contracted HIV in the womb and subsequently developed AIDS. If
this person made the same request of a doctor, the state would likely argue that the killing of this
child would be neither legal nor moral, regardless of the patient’s wealth of experience with
suffering. This argument would likely be couched in an argument pertaining to the innocence of
youth, coupled with an insistence that a child does not have the mental capacity to make such a
choice. Assume then that the child’s request is denied, as the child grows, when would he be able
to exercise the right to ask for an end to suffering through euthanasia? At 16 when the state trusts
him behind the wheel of a potentially extremely dangerous machine? At 18 when he can vote or

3 Vaughn, L. (2013), pg. 601
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21 when he can drink? These ages seem arbitrary (a distinction reflected by their international
and state-level variances), and as the state delays for some pseudo-significant age the patient has
no choice but to wait for his illness to do the moral thing and kill him, and by so doing, free him
of his agony.
Because of the emotional nature of these kinds of questions, it is helpful to consider an
analogous situation to more objectively address the issues at hand. Imagine a hunter walking in
the forest who sees someone being mauled to death by a bear. The bear cannot be killed or
driven away, and the hunter sees that he can shoot this person and save him the agony of being
brutally killed. Regardless of what you think the moral course of action would be, it is clear that
the demographic identity of the victim has no place in the hunter’s decision. It would not further
complicate the hunter’s choice if the person being mauled to death were male or female, young
or old, poor or rich, simply because they are being made to suffer terrible agony before they will
assuredly die. Now imagine the victim sees the hunter and begs to be shot and therefore spared
continued suffering. To stand by and do nothing at that point would certainly be morally wrong,
and as Lachs points out, “In the end, our lives belong to no one but ourselves.Autonomy, Capacity and Dignified Death Essay
” This statement
again holds true without the caveat of ‘unless you’re a child,’ and can be extended to medical
applications. Even if the hunter in this situation was also a bear expert and knew the bear would
leave without killing the victim, the pleas of the person being mauled to death would still
supersede the objective knowledge of the hunter that the person would ultimately ‘survive’.
The other issue this analogy raises, however, is the contentious point of whether or not
medical professionals should be required to actively assist patients who wish to die. Opponents
of euthanasia argue that, “medicine should limit its domain to promoting and preserving human
health,” and should not begin to enter into the relief of “suffering which stems from life itself,Autonomy, Capacity and Dignified Death Essay