Deference to patients risk attitudes is contingent on medical norms
Makin argues that doctors1 should defer to each patient’s attitude to risk, over and above standard, utility-based and outcome-focussed medical decision-making models, in selecting treatment options for that patient.1 Although Makin articulates the problem as a dilemma of whether ‘to give the treatment or to withhold it’, it can be assumed that his question is whether the doctor should offer a certain treatment; because both the General Medical Council and law require doctors to engage patients in shared decision-making (SDM) and to obtain consent before ‘giving’ any treatment. Yet, Makin is c...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Sarela, A. I. Tags: Commentary Source Type: research
Higher-order desires, risk attitudes and respect for autonomy
Nicholas Makins makes a valuable contribution to the literature on medical decision-making, highlighting the role that risk attitudes play in deliberation and subsequently arguing that, in medical choices under uncertainty, if considerations of autonomy and beneficence support deference to patient values and outcome preferences then they also support deference to patients’ attitudes to risk.1 Crucially, however, Makins suggests that it is not simply first-order risk attitudes that are the appropriate target of deference but, rather, patients’ higher-order risk attitudes. In other words, Makins argues that if co...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Kelley, A. E. Tags: Commentary Source Type: research
What about the reasonableness of patients risk attitudes? A challenge to Makins antipaternalistic account
Nicholas Makins proposes that doctors should take a deferential attitude towards their patients’ preferences when making decisions, and this includes their risk attitudes.1 He grounds this proposal in the principles of autonomy and beneficence. Makins appears to hold autonomy as a good in and of itself, and so for him it follows that deferring to patients must also be good. He also seems to hold that the satisfaction of personal preferences inevitably leads to improved well-being, and so deferring to patients’ risk attitudes upholds the principle of beneficence. Unfortunately, Makins explicitly avoids defining ...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Ghinea, N. Tags: Commentary Source Type: research
Autonomy requires more curiosity less deference to risk
In ‘Patients, doctors and risk attitudes,’ Makins argues for ‘straightforwardly’ (Makins1 p1) extending antipaternalistic views about medical decision-making to include deferential considerations of risk attitudes that a patient might endorse. Reflecting on Makins’ important contribution to higher order attitudes in decision theory, we seek to clarify the practical applicability of his argument to specific clinical settings, namely in mental health. We argue that considering low and higher order risk preferences are not only practically difficult, but also potentially ethically fraught and esp...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Wellesley, J., Tumilty, E. Tags: Commentary Source Type: research
On the elusiveness of higher-order risk attitudes
Makins1 formulates a deference principle which states that patients’ attitudes towards the health outcomes associated with different treatment options should drive decision-making and not physicians’ attitudes towards these health outcomes. Although this deference principle is widely agreed on, it is less obvious which role patients’ risk attitudes should play. Makins takes patients’ attitudes towards health outcomes to be sufficiently analogous to patients’ risk attitudes in order to extend his deference principle. His extended deference principle states that patients’ attitudes towards...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Debrabander, J. Tags: Commentary Source Type: research
Emotions and affects: the missing piece of the jigsaw puzzle of understanding risk attitudes in medical decision-making
Nicholas Makins argues persuasively that medical decisions should be made with consideration for patients’ higher order risk attitudes.1 I will argue that an understanding of risk attitudes in medical decision-making is incomplete without critical engagement with emotions and affects (feelings associated with something good or bad). The primary aim of this commentary is to emphasise that clinical decisions are often emotionally charged, and it is crucial to engage closely with emotions and affects that shape these decisions, particularly when navigating complex and uncertain situations. In the face of uncertainty, em...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Subramani, S. Tags: Commentary Source Type: research
Deference, beneficence and the good life
Makins’s analysis of the philosophical justification of decision-making understates and so misinterprets the importance of patient values to ‘the deference principle.’ (Makins N,1, p1) He assesses autonomy and beneficence as two separate arguments in support of deferring to patient preferences, but they only work well considered together. Further, neither the constitutive nor the evidential view of beneficence fully recognises the importance of patient values to understanding the patient’s worldview, which in turn determines what risks and benefits matter most. Revising these arguments enables a muc...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Hanson, S. S. Tags: Commentary Source Type: research
Reconsidering risk attitudes: why higher-order attitudes hinder medical decision-making
In his paper, ‘Patients, doctors and risk attitudes,’ Nicholas Makins1 argues that healthcare professionals should defer to a patient’s higher-order risk attitudes (ie, the risk attitudes they desire to have or endorse within themselves upon reflection) when making medical decisions. We argue against Makins’ deference to higher-order risk attitudes on the basis that (1) there are significant practical concerns regarding our ability to easily and consistently access and verify the higher-order risk attitudes of patients, (2) there is a lack of a theoretical limit on higher-order risk attitudes (eg, s...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Ryan, L. F., Blumenthal-Barby, J. Tags: Commentary Source Type: research
Patients, doctors and risk attitudes
A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are conventionally grounded in a decision maker’s own desires, beliefs and actions. The presence of both doctor and pat...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Makins, N. Tags: Feature article Source Type: research
Involving parents in paediatric clinical ethics committee deliberations: a current controversy
In cases where the best interests of the child are disputed or finely balanced, Clinical Ethics Committees (CECs) can provide a valuable source of advice to clinicians and trusts on the pertinent ethical dimensions. Recent judicial cases have criticised the lack of formalised guidance and inconsistency in the involvement of parents in CEC deliberations. In Manchester University NHS FT v Verden [2022], Arbuthnot J set out important procedural guidance as to how parental involvement in CEC deliberations might be managed. She also confirmed substantive guidance on the role of parental views in determining the child’s be...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Archard, D., Cave, E., Brierley, J. Tags: Current controversy Source Type: research
Epistemic problems with mental health legislation in the doctor-patient relationship
Mental health legislation that requires patients to accept ‘care’ has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. We also examine how the doctor is legally obligated to compound the ep...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Newton-Howes, G., Walker, S., Pickering, N. J. Tags: Clinical ethics Source Type: research
Should medicine be colour blind?
The widely accepted understanding in contemporary discourse is that race and ethnicity fundamentally arose as social constructs devoid of inherent biological or scientific significance.1 Despite this consensus, discussions abound, including in this journal,2 regarding the extent and manner in which racial and ethnic categorisations should influence the landscape of medical research, practice and policy. In an ideal paradigm, medicine should exude an unwavering commitment to impartiality, extending care and treatment to every individual, unfettered by considerations of their racial or ethnic background—an approach tha...
Source: Journal of Medical Ethics - October 23, 2023 Category: Medical Ethics Authors: Suleman, M., Qureshi, Z. Tags: Editorial Source Type: research
Amanitvam: a concept from the Bhagavad Gita applicable in medical ethics
The Bhagavad Gita is one of the most ancient, venerated and popular religious texts originating from India.1 It provides an excellent insight into the tenets of Hinduism. The Bhagavad Gita was originally a part of the Mahabharata,2 and was essentially a dialogue about ethical dilemmas and moral philosophies between a teacher (Krishna) and a disciple (Arjuna). It is considered one of the foundational and most important books in Hinduism. The text provides a synthesis of spiritualism and dharmic ideas, and this text has found widespread acceptance across India, and in regions where there is a strong presence of an Indian dia...
Source: Journal of Medical Ethics - September 22, 2023 Category: Medical Ethics Authors: Simha, A. Tags: Words Source Type: research
Ethics briefings
What’s on the horizon? The Nuffield Council on Bioethics (NCOB) is delighted to pick up the mantel of the Ethics briefings. For readers less familiar with the NCOB’s work, we are a leading independent policy and research centre, and the foremost bioethics body in the UK. We identify, analyse and advise on ethical issues in biomedicine and health so that decisions in these areas benefit people and society.1 Established in 1991, the NCOB has tackled a wide range of bioethics and medical ethics issues over its thirty-two years, including issues relating to the beginning and end of life, health and society, data an...
Source: Journal of Medical Ethics - September 22, 2023 Category: Medical Ethics Authors: Mussell, R., Michaux, N., Gray, M. Tags: Ethics briefing Source Type: research
Global health and global governance of emerging biomedical technologies
Global governance of emerging, disruptive biomedical technologies presents a multitude of ethical problems. The recent paper by Shozi et al raises some of these problems in the context of a discussion of what could be the most disruptive (and most morally fraught) emerging biomedical technology—human germline genome editing. At the heart of their argument is the claim that, for something like gene editing, there is likely to be tension between the interests of specific states in crafting regulation for the technology, and disagreement about what would be necessary to meet the requirements for responsible translation ...
Source: Journal of Medical Ethics - September 22, 2023 Category: Medical Ethics Authors: Cwik, B. Tags: Response Source Type: research
