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Volume 12, Number 2

Ethics and Choice in Health Care: A Third Dimension

Abbyann Lynch

Informed patient choice regarding health care intervention is widely accepted and practised in North America. Ambrosio and Walkerley, the authors of "Broadening the focus: a community perspective on patient autonomy" (pp 26-31), challenge this presumption. Their case: as health care service is increasingly redirected to the community, the acute-care model of patient choice now routinely taught and practised will not suffice. Needed as well: attention to the context within which patient choice is offered (or not), perceived (or not), accepted (or not).

Patient choice is theoretically discussed in terms of personal autonomy. Such autonomy implies choice in terms of self-protection and self-direction. In practice, the issues of concern include capacity to choose, information giving, prevention of coercion, and substitute decision making. In response to these concerns, enabling statutes, agency policies, and guidelines are drafted. Then, ever-more specific issues are addressed. For example: How can we balance the ethical requirements of patient choice with a professional commitment to patient well-being?

While valuable and necessary, these approaches cannot achieve true patient choice in community-based health care until a third dimension is considered: that of context, and the patient's culture within that context. But has this point not already been made? Have not the ethical demands of multiculturalism been routinely acknowledged, and addressed, with reference to patient choice for example, in terms of sensitivity to the patient's religious practice?

Ambrosio and Walkerley contend that this point has indeed been made and taken - but with respect to the acute-care setting only. Thus, emphasis on information needed, or substitute decision making, or choice in situations of 'futility' while relevant in the institutional setting, are not helpful beyond it. In addition, the authors challenge us to consider choice for "people in the community." These people "do not so much fear overtreatment as...denial of treatment, or not being offered treatment that is appropriate to their needs. A concept of autonomy, focussed on informed consent and driven by the belief that the individual's freedom to choose is enhanced by the provision of information and an ability to understand the issues, does not work for those individuals in the community who have the relevant information and understand the issues, but have no control over the resources they need to make their choice."

Thus, how is patient choice to be exercised by the individual living in poverty who cannot go to hospital, or by the individual whose 'residence' prevents any possibility of 'discharge to home'? What health care choices can be made by individuals who have no access to the system because they do not understand it or have no means to use it: for example, Carol's lost health card (p29 of Ambrosio and Walkerley's manuscript)? What choice is there for those individuals who are refused admission to acute-care settings because their situation is not sufficiently acute, but who have no other means of obtaining assistance? For all these individuals, patient choice is a meaningless phrase; the 'patient choice' of the acute-care setting does not apply to their situation in the community.

How to remedy the difficulty? The authors suggest that somehow ethicists must become free from ties to specific hospitals and their policies when considering community-based questions of patient choice. They recommend that hospitals, "with input from their communities, should develop flexible policies that broaden rather than restrict patient options and that the process could begin with a joint committee (hospital and community) ...with the power to effect change."

Patient choice in the absence of options is meaningless. To achieve ethically sound, community-based patient choice, the community first must make available and help individuals to know that such resources exist. Even so, individuals still must be empowered within their culture so that they can truly choose to accept or refuse the use of those resources.

Is patient choice a reality? Not for all persons - not yet.

Ethics in Health Care Associates, Toronto
Correspondence and reprint requests: Abbyann Lynch, PhD, Director, Ethics in Health Care Associates, Toronto, Ontario, Canada