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Published online by Cambridge University Press: 29 November 2010
Surgical care of elderly persons focuses many of the difficult legal and ethical dilemmas that have arisen in modern medicine. Such issues arise at both macro and micro levels. This paper explores four micro level areas involving physician-patient interaction. These are: informed consent, dying patients, pain relief treatment and medical research, when the patients involved are elderly persons.
The discussion of informed consent includes consideration of refusal of treatment, scope of information, voluntariness, coercion and competency. In particular, the basic presumptions are articulated and variations in the application of these concepts, when aged persons are involved, and justification of such variations, are considered. Within the topic of dying elderly persons, the “living will” and “durable powers of attorney” are discussed. The obligation to provide pain relief treatment can be particularly important in the context of terminally ill and dying persons and it is suggested that there should be a legal obligation to provide such treatment, including in some circumstances, where the treatment could possibly, or even is likely to, shorten life. Finally, aged persons' participation in medical research and the special problems that can be involved in this are addressed.
In conclusion, it is suggested that the greater visibility and identification of old persons needing surgery than of those needing some other forms of medical care is likely to make this an important arena for setting far-reaching precedents regarding humane approaches to, and human rights in, access to and provision of medical care.
La question des traitements chirurgicaux pour les personnes âgées met en lumière plusieurs des problèmes juridiques et éthiques liés à la pratique médicale contemporaine. Ces dilemmes se soulèvent tant au niveau global qu'au niveau particulier. L'allocution traitera de quatre questions reliées au rapport entre le médecin et le patient âgé, à savoir: le consentement éclairé, les patients en phase terminale, les traitements analgésiques, et la recherche médicale.
Le problème du consentement éclairé sera envisagé sous différents aspects, soit le refus de traitement, l'étendue de l'obligation d'information, le caractère volontaire du consentement, la pression indue et la capacité du patient. En particulier, on abordera les fondements de ces concepts, et on tentera d'identifier et de justifier les conséquences différentes qu'il faut en tirer lorsque le patient est une personne âgée. On s'attardera aussi sur le problème du “living will” et sur celui des procurations dont l'effet se poursuit après l'incapacité du patient (le “durable power of attorney”), en rapport avec la question des patients en phase terminale. Le problème du traitement analgésique est particulièrement aigu pour ces derniers; on suggérera qu'il exute un obligation juridique de fournir un tel traitement. Cette obligation existe dans certains cas même si un tel traitement est susceptible de réduire l'espérance de vie du patient. Enfin, on traitera des questions soulevées par la participation des personnes âgées à différentes expériences dans le contexte de la recherche médicale.
En raison de sa grande visibilité et de la facilité avec laquelle on peut identifier les individus âgés dont l'état nécessite une intervention chirurgicale, le domaine des soins chirurgicaux pour les personnes âgées devrait permettre de développer différentes approches plus humaines en matière médicale, et de définir des droits fondamentaux en matière de prestation et d'accès aux soins de santé. Ces nouveaux développements auront sans doute un impact important dans d'autres secteurs des services de santé.
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2. For references to some of this literature, see Somerville, M.A., “Consent to Medical Care”, Protection of Life Series, Law Reform Commission of Canada, Ottawa, 1979.Google Scholar
3. Katz, J., “The Silent World of Doctor and Patient”, The Free Press, New York, 1984, p. 191.Google Scholar
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5. See, for example, Reibl v. Hughes (1980) 114 D.L.R. (3d) 1 (S.C.C.).
6. See Somerville, M.A., “Structuring the Issues in Informed Consent”, (1981) 26 McGill Law Journal 741.Google Scholar
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8. Tversky, and Kahneman, , “The Framing of Decisions and the Psychology of Choice”, Science 211; 453 (1981).Google Scholar
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10. Ibid.
11. Ibid., p. 351.
12. Somerville, supra, note 6.
13. See, for example, Kelly v. Hazktt (1976) 15 O.R. (2d) 290 (Ont. CA.), p. 318.
14. See, Reibl v. Hughes, supra, note 5, pp. 10–11.
15. Order in Council 3322–72 (8 November 1972), passed pursuant to the Health Services and Sodai Services Act, R.S.Q., c S–5, Quebec Legislature.
16. See Lawton, M.P., “Psychological Vulnerability of Elderly Subjects”, in “Protection of Elderly Research Subjects”, Summary of the National Institute on Aging Conference July 18–19, 1977, DHEW Publication No. (NIH) 79–1801; 6, p. 12.Google Scholar
17. Somerville, supra, note 6.
18. See, for example, Dependent Adults Act R.S.A. 1980, c. D–32 (Alberta).
19. For an in-depth discussion of the concept referred to here, see Somerville, M.A., “Refusal of Medical Treatment in ‘Captive’ Circumstances”, (1985) 63 Can. Bar Rev. 59.Google Scholar
20. Such a case could arise where the surgeon wanted to test the validity of the consent of a doubtfully competent person to a non-therapeutic intervention, for example, non-therapeutic contraceptive sterilization, when the law only allows this to be undertaken on competent persons with their informed consent.
21. Roth, L.H., Meisl, A., Lidz, C.W., “Tests of Competence to Consent to Treatment”, American Journal of Psychiatry 134: 279 (1977).Google ScholarPubMed
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23. See, Somerville, supra, note 19.
24. Supra, p. 130.
25. Katz, supra, note 3, pp. 190–195.
26. Somerville, supra, note 19.
27. See, Ibid.
28. See, for example, Re Superintendent of Family and Child Services andDawson et al. (1983) 145 D.L.R. (3d) 610 sub. nom. Re S.D., [1983] W.W.R. 618 (B.C.S.C).
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30. Katz, supra, note 3, p. 223.
31. Somerville, M.A., “Pain and Suffering at Interfaces of Medicine and Law”, (1986) XXXVI University of Toronto Law Journal, 286.Google Scholar
32. Ibid.
33. Ibid.
34. Somerville, M.A., “Clarifying the Concepts of Research Ethics: A Second Filtration”, Clinical Research 29(2): 101–105 (1981)Google ScholarPubMed; Somerville, M.A., “Therapeutic and Non-therapeutic Medical Procedures-What are the Distinctions?” (1981) 2 Health Law in Canada (2) 85.Google Scholar
35. An example of a situation in which such an aim would not be present, is where kidneys from aborted fetuses are transplanted into the arms of research subjects in order to test the functioning and continued growth of the kidneys and whether or not they are rejected by the host research subject.
36. “The Report of the Massachusetts Task Force on Organ Transplantation”, reported in pan in (1985) 13 Law Medicine and Health Care, 8.