Divergence in healthcare decision-making : seeking a consensus on the meaning and application of 'best interests'

Johnston, Carolyn (2011) Divergence in healthcare decision-making : seeking a consensus on the meaning and application of 'best interests'. (PhD thesis), Kingston University, .


The concept of best interests lies at the core of my work. 'Best interests' underpins all healthcaremaking whether orientated to treatment of an individual or which impact on a community. My publications explore the respect accorded to an individual's view of his own best interests in decision-making, both for contemporary and future decisions and how this may conflict patient welfare, objectively perceived. They also consider the weight given to different of those involved in deciding what treatment option is 'best' for a patient lacking and whose view predominates when there is conflict. I have also written on the tension individual best interests and the wider interests of society. My publications have increasingly moved from describing the meaning and application of 'best interests', particularly with reference to the Mental Capacity Act 2005 (MCA), to focusing on how the legal provisions may be in practice - a translational approach. I have also explored the role of medical education equipping doctors of tomorrow to make informed decisions about best interests and how clinical and ethics committees may elucidate the meaning, and ensure the proper analysis, of best interests in a for resolving conflicts in healthcare decision- making. The importance of the assessment of best interests in health-care decision making cannot be overstated. Failure to acknowledge and give respect to the views of comptetent patients or the parents of young children may result in loss of trust in healthcare professionals and disengagement wit services. giving due regard to the values and wishes of adult patients who lack capacity is fundamnetal to protect and promote the interests of the most vulnerable members of society. However, the mere mantra of 'best interests' belies the complexity of the assessment and its application in practice. Clinicians, family members, and the patient himself may have differing interpretations of best interests. The weight given to these perspectives may depend not on the level of evidence required to adduce these views but also on how far they move away promoting the basic interests of the patient, such as dignity, freedom from pain and suffering, life itself. My thinking on this topic has developed through my research and writing, particularlythe qualitative research I have undertaken, and I now come to the view that bst interests impose a normative standard which is interpreted through the subjective lens of various stakeholders in the decision making process, as Atkins notes, "the problem of trying to capture something unique using tools proper to something general." (Atkins, 200, p.72). My approach to best interests in healthcare decision-making derives from a wide range of professional experience. After training as a solicitor I took an LLm in law and nearly 20 yeras ago started teaching at Kingston University on a fractioanl appointment. I developed an interest in medical law and ethics, and following an MA in Medical Law and Ethics I taught this subject to final year law students at Kingston. My work with The Ethox Centre, University of Oxford focusing on clinical ethics support, enabled me to gain insight in to the role of clinical ethics committees as part of the process of decision-making and as a member of three clinical ethics committees I am able to observe the range of different clinical settings which give rise to challenging issues in best interests. More recently I have been involved with the Institute of Medical Ethics Education Project in developing the core medical undergraduate curriculum in medical ethics and law. If medical students are not confident about their knowledge of key medico-legal and ethical issues then as young doctors they will not feel able to challenge poor practice or promote' better patient care "through using legal rules and an understanding of how law relates to and underpins good medical practice" (Preston - Shoot, 2011, P 6). I also teach medical law and ethics at the School of Medicine, King's College London and this gives me first-hand experience of the way both medical students and clinicians approach the tension between respecting patient autonomy and the duty to 'benefit' the patient. Through my qualitative research focusing on practitioners' interpretations of best interests my recent publications on adolescent decision-making (2009) and clinical ethics committees (2010) set the legal analysis in the context of the practice of medicine and methods of resolving divergence in decision- making. In this Introductory Section I will demonstrate how my publications form a coherent body of knowledge through the exploration of the concept of best interests in different contexts of healthcare decision-making. I shall review my publications with reference to normative expectations and subjective accounts of best interests and the balance between the best interests of an individual and the wider interests of society.

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