What happens when a patient declines care but may not have the capacity to provide consent? What defines informed consent? What are ethical obligations and challenges when providing care to vulnerable patient populations?
New Ethics in Practice articles in JBJS offer thoughtful discussion of such questions and related ethical considerations that arise for orthopaedic clinicians.
- In Capacity and Declination of Care in the Surgical Patient, Lightsey et al. present a case scenario of an orthopaedic trauma patient with alcohol-use disorder and schizoaffective disorder who initially declines proposed surgical treatment and is evaluated for the capacity to make an informed decision. The authors discuss the concept of capacity and key criteria in assessing capacity, and they outline a multidisciplinary approach involving orthopaedic surgery, psychiatry, social work, ethics, and hospital legal counsel. “Caring for a patient with limited or fluctuating capacity presents a variety of challenges, which are further compounded by declination of life-changing care. Proper care for such patients necessitates multidisciplinary efforts to uphold beneficence, avoid maleficence, and respect patient autonomy,” they write. Read the article by Lightsey et al.
- In another recent article, Informed Consent in Orthopaedic Surgery: A Primer, Hershfeld et al. assess the informed consent process, probing 4 questions: (1) What defines informed consent? (2) Can informed consent be objectively measured? (3) What barriers impede adequate informed consent? (4) What legalities are involved in malpractice claims relating to informed consent? “The reasonable-person standard of informed consent may satisfy legal requirements, but physician subjectivity allows for paternalism and loss of autonomy,” they write. “To standardize informed consent, objective measures must be considered. It is advised that providers receive formal training on the informed consent process. With increased physician awareness of barriers to adequate informed consent, patient autonomy can be better preserved.” Read the article by Hershfeld et al.
- In their article Establishing Orthopaedic Standards of Care for Incarcerated Patients: Ethical Challenges and Policy Considerations, Peairs et al. point out that musculoskeletal and connective tissue diseases are the second-most common category of illness among incarcerated patients. The authors explore how the unique setting of prisons and jails impacts the delivery of orthopaedic care to patients, and they apply the ethical principles of beneficence, nonmaleficence, autonomy, and justice in discussing physician responsibilities when caring for patients who are incarcerated. “The correctional health system places surgeons in tension with several principles of ethical health-care delivery,” they say. “It is imperative that, as physician-leaders responsible for improving the care of all patients, the surgical community takes steps to adopt policies that bridge the gaps in care that exist for patients who are incarcerated.” They outline 5 steps toward this end. Read the article by Peairs et al.