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AETCOM Module 2 session 5 MBBS curriculum India content topics
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AETCOM Module 2.5
Bioethics Continued - Case Studies on Patient Autonomy and Decision Making
Year of Study: Professional Year 2 (MBBS Second Year)
Source: NMC AETCOM Book
Competency Addressed
The student should be able to:
Identify, discuss, and defend medicolegal, sociocultural, and ethical issues as they pertain to patient autonomy, patient rights, and shared responsibility in healthcare. (Level: KH - Knowledge and Higher order application)
Background
The important parts of ethical care of the patient are best learnt in a hybrid problem-based format with additional lectures and other sessions that allow students to learn collaboratively. This module introduces patient autonomy and decision-making through case studies.
Learning Experience Structure
| Session | Type | Duration |
|---|---|---|
| i. | Introduction of case | 1 hour |
| ii. | Self-directed learning | 2 hours |
| iii. | Anchoring lecture | 1 hour |
| iv. | Discussion and closure of case | 1 hour |
| Total | 5 hours |
Core Topics for Discussion
- Extent of patient autonomy - how far does a patient's right to decide extend?
- Elements in decision making: Competency vs. Capacity
- Competency = legal determination (made by a court)
- Capacity = clinical determination (made by the treating doctor at a specific time/decision)
- Surrogacy in decision making - who decides when the patient cannot?
- Autonomy vs. Beneficence - when what the patient wants conflicts with what is medically best
- How much do family wishes count? - the role of the family in Indian social/cultural context
- Legal, ethical, and social aspects of "Do Not Resuscitate" (DNR)
Key Concepts Explained
Patient Autonomy
The right of a competent patient to make informed decisions about their own healthcare, including the right to refuse treatment even if that decision may harm them. Autonomy requires:
- Information - the patient must be adequately informed
- Voluntariness - the decision must be free from coercion
- Capacity - the patient must have decision-making capacity
Competency vs. Capacity
| Feature | Capacity | Competency |
|---|---|---|
| Who determines | Clinician (doctor) | Court of law |
| When assessed | Time/decision-specific | Legal ruling |
| Nature | Clinical concept | Legal concept |
| Fluctuation | Can fluctuate | More permanent |
A patient may have capacity for some decisions but not others. Capacity is assessed for each specific decision.
Surrogacy in Decision Making
When a patient lacks capacity, a surrogate decision-maker steps in. The hierarchy typically is:
- Legal guardian / healthcare proxy (advance directive)
- Spouse
- Adult children
- Parents
- Other family members
The surrogate should follow the substituted judgment standard (what would the patient have wanted?) rather than personal preference.
Autonomy vs. Beneficence
This is a classic ethical tension:
- Autonomy = respecting the patient's right to decide, even a "bad" decision
- Beneficence = acting in the patient's best medical interest
- In modern medical ethics, autonomy generally takes precedence over paternalistic beneficence for competent adult patients
Do Not Resuscitate (DNR)
- A DNR order means no CPR will be attempted if the patient's heart stops
- Must be patient-initiated (or surrogate if patient lacks capacity)
- In India: no specific legislation; guided by medical ethics and hospital policy
- Key considerations: patient's right to die with dignity, family distress, medico-legal concerns
Assessment
Formative: Active participation in sessions
Summative - Short answer questions:
- a) What determines decision-making capacity and competency?
- b) Who has the right to make decisions for a patient who cannot decide for himself?
Suggested Additional Reading
- Mani RK, Amin P, Chawla R, et al. ISCCM position statement: Limiting life-prolonging interventions and providing palliative care towards the end of life in Indian ICUs. Indian J Crit Care Med. 2005;9:96-107.
- The module builds on concepts from Module 2.2 (Foundations of Bioethics) and connects forward to Module 2.6 and 2.7 (further case studies on autonomy).
Connection to the Four Principles of Bioethics (Module 2.2 Recap)
Since Module 2.5 is a continuation of bioethics, it builds on the four Beauchamp & Childress principles:
| Principle | Definition |
|---|---|
| Autonomy | Respect patient's right to self-determination |
| Beneficence | Act in the patient's best interest |
| Non-maleficence | Do no harm |
| Justice | Fair distribution of healthcare resources |
Module 2.5 focuses specifically on Autonomy in depth through real-world case scenarios.
Tip for exams: Be able to distinguish between capacity (clinical, fluctuating, decision-specific) and competency (legal, determined by court). Also know the surrogate decision-making hierarchy and the principle that a competent patient's autonomy generally overrides the doctor's paternalistic beneficence.
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