Informed Consent and Autonomy

Antihypertensive and the Risk of Temporary Impotence: A Case Study of Informed Consent

            Mr. Williams has presented Dr. Kramer with an interesting question of informed consent. Dr. Kramer is caught between doing what is right for the patient versus respecting Mr. William’s autonomy. Dr. Kramer should have a serious discussion with Mr. Williams describing in detail her recommended course of treatment and the possible side effects including impotence.

            There are four possible outcomes in this model. One is a known variable that is to be made by Dr. Kramer. She can choose either disclose to Mr. Williams the possible side effect of impotence or not. For each decision that Dr. Kramer could make, Mr. Williams will either choose hydrochlorothiazide or not as a therapy to control his high-blood pressure. This situation is analogous to a finite state machine that has two possible outcomes that are determined by two possible inputs. Similarly, the choice to use hydrochlorothiazide is a function of Dr. Kramer’s decision.

            If Dr. Kramer tells Mr. Williams about the possible side effects of hydrochlorothiazide then Dr. Kramer has fulfilled her duty to inform the patient fully and respected Mr. Kramer’s rights to autonomy and self-governance (G. Dworkin, pg. 103). This disclosure facilitates the patient’s decision-making process so they can choose an outcome that best suits their desires. If Mr. Williams chooses hydrochlorothiazide then everybody is happy and the possibility of a poor outcome is nil, because regardless of the presence of impotence. Each party in this transaction was informed. Now if Mr. Williams chooses not to take the drug then he understands the consequences of his decision: either another higher priced drug or continued hypertensive issues. This decision made by Mr. Williams gives the patient his autonomy of choice because the decision to take this medicine has quality of life issues associated with it that only Mr. Williams has the ability to place relative value upon. For example Dr. Kramer does not have the right to claim that his long-term health is more important than his relationship with his new wife.

            If Dr. Kramer decides not to disclose to Mr. Williams about the possible side effects of the medication then Dr. Kramer is acting in a paternalistic way. Since the 1970’s in the United States the paternalistic model of the Doctor-Patient relationship has been thrown out; the modern widely accepted model of autonomy in medicine is “that adult citizens of normal competence have a right to autonomy, that is, a right to make decisions about the character of their lives for themselves” (R. Dworkin, pg. 6).

Despite the disrespect to Mr. Williams’ autonomy, Dr. Kramer decides not to disclose the side effects to Mr. Williams. There is a high probability that he will choose the medication because of limited side effects and an agreeable price. Therefore considering the outcome of disclosing the possible side effects and Mr. Williams not choosing the medication will not be examined. If he chooses the medication then there is a 3-5% chance that he will experience impotence. If Mr. Williams does not experience any side effects then all parties are happy. In the worst outcome, Mr. Williams’ quality of life decreases and he doesn’t know why and doesn’t disclose that to Dr. Kramer and overall Mr. Williams is unhappy. While in a less extreme case he discloses to Dr. Kramer that he is having sexual dysfunction and then the same outcome would be reached as if Dr. Kramer told Mr. Williams and he choose not to take the drug, only in addition Mr. Williams distrusts Dr. Kramer and Mr. Williams is unhappy.

Despite the low probability of a poor outcome, Dr. Kramer does not have the right to judge the importance of the outcome. By not disclosing to Mr. Williams the possible side effect of impotence she is in effect making the decision for the patient that a 3-5% chance of this side effect occurring is a risk worth taking. Even if the percentage of impotence is .001%, the decision to accept a risk can only be made by Mr. Williams because he alone is the only person who can evaluate and normalize risk in the context of his life and his vision of what he wants his life to look like. This personal autonomy can led patients to make decision that sometime appear objectively not in their best interest as would be the case if Mr. Williams choose not to start hydrochlorothiazide after hearing about the possible side effects.

Among physicians in the medical world it is recognized that the paternalistic model is required when there are times of emergency or incompetence. Ackerman makes the argument that illness interposes the mind and body from reality (Ackerman, pg. 16). Therefore it is the goal of the physician to restore autonomy to the patient by intervening and guiding the patient though the treatment process. This does not apply to the case of Dr. Kramer and Mr. Williams. By all accepted standards Mr. Williams is competent, he is not in extreme pain, suffering a debilitating mental illness, or hindered mentally by this illness. He is capable of comprehending his situation and therefore is capable of making his own decisions.

            This issue of informed consent and the intersection of autonomy are a complex issue. Dr. Kramer’s responsibility is to make sure the patient has the best outcome. Parfait’s summation of the theories of welfare concludes that people have subjective preferences for objective goods (Parfait, pg. 502). Mr. Williams’ desire to please his wife might rate higher than his desire to have a healthy blood pressure. Regardless of these measures, Dr. Kramer has no right to determine Mr. William’s desires and act upon these perceived desires. Therefore the decision to be paternalistic and not disclose information undermines the personal autonomy of Mr. Williams.