The article calls for a departure from the common concept of autonomy in two significant ways: it argues for the supremacy of semantic understanding over procedure, and claims that clinicians are morally obliged to make a strong effort to persuade patients to accept medical advice. We interpret the value of autonomy as derived from the right persons have to respect, as agents who can argue, persuade and be persuaded in matters of utmost personal significance such as decisions about medical care. (...) Hence, autonomy should and could be respected only after such an attempt has been made. Understanding suffering to a significant degree is a prerequisite to sincere efforts of persuasion. It is claimed that a modified and pragmatic form of discourse is the necessary framework for understanding suffering and for compassionately interacting with the frail. (shrink)

Despite significant advances in medicine, death remains a certainty for every living human being. End-of-life care decision-making is not made easier in a multi-cultural and multi-religious society like Malaysia. As such, planning for one's death by making Advance Decisions can be immensely valuable as it can help healthcare providers in Malaysia to understand better the preferences and wishes of their patients. However, compared to other countries, there is currently no specific legislation on any form of Advance Decisions in Malaysia despite (...) many doctors voicing a need for them. Unlike the Mental Capacity Act 2005 in the UK, the Malaysian Mental Health Act 2001 does not cover all instances of incapacity and only applies to those who suffer from a mental disorder as defined in the Act. In the absence of legislation, one could look to ethical guidelines, especially from the Malaysian Medical Council, but find that this can sometimes be problematic. It is argued that a concerted effort involving all relevant parties is required to develop a pragmatic and viable Advance Decisions frameworkl in Malaysia. (shrink)

Advance care planning is a voluntary process whereby individual preferences, values and beliefs are used to aid a person in planning for end-of-life care. Currently, there is no local instrument to assess an individual’s awareness and attitude towards advance care planning. This study aimed to develop an Advance Care Planning Questionnaire and to determine its validity and reliability among older people in Malaysia. The Advance Care Planning Questionnaire was developed based on literature review. Face and content validity was verified by (...) an expert panel, and piloted among 15 participants. Our study was conducted from October 2013 to February 2014, at an urban primary care clinic in Malaysia. Included were those aged >50 years, who could understand English. A retest was conducted 2 weeks after the first administration. Participants from the pilot study did not encounter any problems in answering the Advance Care Planning Questionnaire. Hence, no further modifications were made. Flesch reading ease was 71. The final version of the Advance Care Planning Questionnaire consists of 66 items: 30 items were measured on a nominal scale, whilst 36 items were measured on a Likert-like scale; of which we were only able to validate 22 items, as the remaining 14 items were descriptive in nature. A total of 245 eligible participants were approached; of which 230 agreed to participate. Factor analysis on the 22 items measured on a Likert-scale revealed four domains: “feelings regarding advance care planning”, “justifications for advance care planning”, “justifications for not having advance care planning: fate and religion”, and “justifications for not having advance care planning: avoid thinking about death”. The Cronbach’s alpha values for items each domain ranged from 0.637–0.915. In test-retest, kappa values ranged from 0.738–0.947. The final Advance Care Planning Questionnaire consisted of 63 items and 4 domains. It was found to be a valid and reliable instrument to assess the awareness and attitude of older people in Malaysia towards advance care planning. (shrink)

Bioethicists think about families in terms of conflicting interests. This mistake results from an impoverished notion of informed consent. Only by adequately characterizing the process of informed consent can we capture the phenomenon of shared decisionmaking.

Recognition that the Principle of Respect for Autonomy fails to work in family-centric societies such as Singapore has recently led to the promotion of relational autonomy as a suitable framework within which to place healthcare decision making. However, empirical data, relating to patient and family opinions and the practices of healthcare professionals in Confucian-inspired Singapore, demonstrate clear limitations on the ability of a relational autonomy framework to provide the anticipated compromise between prevailing family decision-making norms and adopted Western led atomistic (...) concepts of autonomy. Evidence suggests that despite a growing infusion of Western influence, there is still little to indicate any major shift to individual decision making, particularly in light of the way society and healthcare are structured. Similarly, the lack of employing a shared decision-making model and data that discredit the notion that the complex psychosocial and cultural factors that affect the decision making may be considered “content neutral” not only prevents the application of relational autonomy but questions the viability of the values behind the Principle of Respect for Autonomy. Taking into account local data and drawing upon a wider concept of personhood that extends beyond prevailing family-centric ideals along with the complex interests that are focused upon the preservation of the unique nature of personhood that arises from the Ring Theory of Personhood, we propose and “operationalize” the employing of an authoritative welfare-based approach, within the confines of best interest decision making, to better meet the current care needs within Singapore. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

In der modernen Medizin kommt es zunehmend zu Entscheidungskonflikten zwischen Intervention und Interventionsverzicht dort, wo nicht die medizinisch-technischen Möglichkeiten handlungsleitend sein sollen, sondern die am individuellen Patientenwohl sich orientierende bioethische Prognose entsprechend den klassischen arztethischen Prinzipien des primum nil nocere und des salus aegroti suprema lex. Schadensverbot und Heilauftrag sollen nicht heteronom und uniform vorgegeben werden, sondern sich am Willen des Patienten orientieren. Nicht selten macht jedoch die Ermittlung des mutmaßlichen Patientenwillens große Schwierigkeiten, vor allem bei Demenz, Koma, schwerem Trauma (...) und Multimorbidität in der Nähe des Todes. Vorsorgliche Betreuungsvollmachten und Behandlungsverfügungen, fälschlich oft 'Patiententestament' genannt, sind als Instrumente für stellvertretende Entscheidungen und zur Ermittlung des Patientenwohles in solchen Situationen vorgeschlagen worden. Der Beitrag analysiert die entscheidungstheoretischen, ethischen, rechtlichen und medizinischen Aspekte prospektiver Entscheidung über eine medizinische Behandlung in einem transkulturellen und interdisziplinären Vergleich von Entscheidungen und Diskussionen in den USA, Japan und der Bundesrepublik Deutschland. Es werden verschiedene Modelle und Betreuungsverfügungen mit unterschiedlicher rechtlicher und medizinischer Validität und Präzision sowie unterschiedlicher kultureller und individueller Akzeptanz entwickelt und diskutiert. (shrink)