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Physicians’ personal values in determining medical decision-making capacity: a survey study
  1. Helena Hermann,
  2. Manuel Trachsel,
  3. Nikola Biller-Andorno
  1. Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
  1. Correspondence to Professor Nikola Biller-Andorno, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Pestalozzistrasse 24, Zürich CH-8032, Switzerland; biller-andorno{at}ethik.uzh.ch

Abstract

Decision-making capacity (DMC) evaluations are complex clinical judgements with important ethical implications for patients’ self-determination. They are achieved not only on descriptive grounds but are inherently normative and, therefore, dependent on the values held by those involved in the DMC evaluation. To date, the issue of whether and how physicians’ personal values relate to DMC evaluation has never been empirically investigated. The present survey study aimed to investigate this question by exploring the relationship between physicians’ value profiles and the use of risk-relative standards in capacity evaluations. The findings indicate that physicians’ personal values are of some significance in this regard. Those physicians with relatively high scores on the value types of achievement, power-resource, face and conformity to interpersonal standards were more likely to apply risk-relative criteria in a range of situations, using more stringent assessment standards when interventions were riskier. By contrast, those physicians who strongly emphasise hedonism, conformity to rules and universalism concern were more likely to apply equal standards regardless of the consequences of a decision. Furthermore, it has been shown that around a quarter of all respondents do not appreciate that their values impact on their DMC evaluations, highlighting a need to better sensitise physicians in this regard. The implications of these findings are discussed, especially in terms of the moral status of the potential and almost unavoidable influence of physicians’ values.

  • Autonomy
  • Capacity
  • Ethics
  • Informed Consent
  • Paternalism

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Introduction

Evaluations of patients’ medical decision-making capacity (DMC) are complex endeavours with far-reaching ethical implications in terms of patients’ self-determination.1 It is widely agreed that such evaluations are ultimately based on the healthcare practitioner’s clinical judgement, integrating diverse information about patients’ functional abilities and mental status and about contextual and situational factors.2 Furthermore, it is acknowledged that DMC judgements are achieved not on descriptive grounds alone but are tightly bound to normative considerations.3 ,4 These involve questions concerning the relevance of various mental abilities and the necessary extent of their integrity.5 Moreover, the eventual question to be answered is whether or not the patient in his or her current state ought to be deemed capable for making the specific decision at hand.1 ,6 As a consequence, it is assumed that DMC judgements are always to a certain degree influenced by the normative climate in a society as well as by the personal value system of the healthcare practitioner who evaluates a patient’s DMC.

Such personal influences are important from an ethical perspective insofar as patients may be evaluated differently depending on which physician they encounter, potentially yielding different competence judgements of similar patients and resulting in arbitrariness. Furthermore, a physician's values may impact unduly on competence judgements, reflecting unjustified paternalism and so jeopardising patient autonomy.

In his influential work The Nature of Human Values, Rokeach defines value asan enduring prescriptive or proscriptive belief that a specific mode of behavior or end-state of existence is preferred to an oppositive mode of behavior or end-state. This belief transcends attitudes toward objects and toward situations; it is a standard that guides and determines action, attitudes toward objects and situations, ideology, presentation of self to others, evaluations, judgements, justifications, comparisons of self with others, and attempts to influence others (ref. 7, p.25).

Moreover, values are organised in a value system along a continuum of relative importance whereby individual differences in such value systems evolve from variations in personal, societal and cultural experiences.7

Empirical research on DMC has been primarily concerned with patients’ functional abilities; factors on the side of the evaluator have rarely been investigated. To our knowledge, there are no studies looking at the relationship between healthcare practitioners’ personal values and their DMC evaluation practice. The present study set out to explore whether or not such relationships exist, and what form they take. More specifically, the study aimed to investigate these relations with regard to the issue of risk-relativity, to establish whether or not physicians with particular values are more or less likely to use risk-relative standards in DMC evaluations.

Risk-relativity refers to the idea that, as a function of the risk-benefit profile of a certain decision, more or less stringent, or different, criteria of mental capability are required for deeming a patient competent. For example, if the treatment choice carries only a minor risk, it suffices that the patient understands the given information; whereas if a high-risk option is chosen, he or she must additionally be able to weigh the given information in light of his or her own values. Risk-relativity differs from considerations of other decision-specific factors such as the complexity of the decision. While risk-relativity calls for different standards, the complexity of a decision demands different levels of abilities which are, however, captured by consistent standards. For example, with increasing complexity, better abilities are required to understand information, but the standard remains unchanged (namely, understanding). Risk-relativity remains a matter of debate and controversy. While some authors regard considerations of risk as an inevitable feature of DMC evaluations because they seem the only reasonable way of determining thresholds for mental abilities,1 ,2 others express great concern that risk-relativity may be a means of introducing inappropriate medical paternalism through the back door.8 Risk-relativity is therefore an important factor in any investigation of the relationship between physicians’ values and DMC evaluations because of the potential of practitioners’ personal values to unduly influence risk-relative evaluations.

As a broader goal, the study seeks to provide an empirical basis for further ethical reflection on how DMC evaluations may be affected by physicians as individuals.

Method

The present investigation was part of a larger cross-sectional survey study on ‘Decision-making Incapacity at the End of Life and its Assessment in Switzerland’.9

Participants

The participants under investigation formed a subsample of the abovementioned study, comprising 637 senior physicians with accredited medical specialisms and practicing in Switzerland who filled out a questionnaire in the context of the larger study and an additional questionnaire on physicians’ values (inclusion of 83.5% of the larger study's participants, corresponding to a response rate of 18.3%). Participants were recruited via mail, and were offered the option of completing the questionnaire by means of either a paper-pencil version or an online link. Data collection lasted from June to November 2013.

Questionnaires

To assess physicians’ attitudes towards risk-relativity, three questions were formulated. The first item, presented as a four-point Likert scale (not at all relevant to very relevant), asked physicians how relevant they considered the consequences of a decision for DMC evaluations to be, in terms of severity of risk. The following example was given to better illustrate what is meant: You apply, for example, higher standards in terms of mental abilities, if the decision has serious adverse consequences.

The next two questions were formulated as consecutive case vignettes, describing options with increasing severity of consequences in terms of life expectancy, from treatment consent to chemotherapy (high probability of survival) to treatment refusal of chemotherapy (high probability of death within a short time) to assisted suicide (immediate death) (see box 1). In each vignette, physicians were asked to indicate whether and in which case (treatment consent vs treatment refusal; treatment refusal vs assisted suicide) they would apply more stringent standards in relation to mental abilities.

Box 1

Case vignettes

Chemotherapy:

A patient has to decide whether or not he wants his cancer to be treated with chemotherapy. If the patient undergoes chemotherapy, the chance of having the tumour growth stopped without recurrence will be 70%. Refraining from treatment on the other hand will likely result in death within a few months. There are no other pertinent treatment options. The patient's medical decision-making capacity is doubted and needs further examination.

In which case do you apply higher standards in terms of mental abilities for assessing medical decision-making capacity?

  1. The patient chooses to undergo chemotherapy.

  2. The patient chooses not to undergo chemotherapy (treatment refusal).

  3. In both cases, I apply equally stringent standards in terms of mental abilities.

Assisted suicide:

The same patient (from the chemotherapy vignette above) decided not to undergo chemotherapy (treatment refusal). Instead he asks for assisted suicide.

You are consulted to evaluate the patient's medical decision-making capacity.

Which standards must be fulfilled to deem the patient capable? (multiple answers possible)

  1. I apply more stringent standards in terms of mental abilities as in the case of treatment refusal.

  2. I apply equally stringent standards in terms of mental abilities as in the case of treatment refusal.

  3. I must be personally convinced that assisted suicide is the best option available for the patient.

Moreover, in the assisted suicide vignette, an additional option was presented to directly elicit whether or not physicians would take their own stance on assisted suicide as a criterion for deeming the patient competent.

In addition, physicians were asked to indicate on a four-point Likert scale (not at all to very) to what extent they thought their own values would influence DMC evaluations.

For the assessment of physicians’ personal values, a refined instrument of the extensively researched Schwartz Value Scale was used (Portrait Value Questionnaire Revised).10 In comparison to the original scale11 that measures 10 basic values, the refined version partitions the array of values into a finer set of 19 meaningful and conceptually distinct values (table 1). Each value is defined by a motivational goal that serves as a guiding principle in the life of a person. For example, a person who strives trans-situationally and exceedingly for pleasure and sensuous gratification—a motivating goal for this person—scores high on the value referred to as ‘hedonism’ by Schwartz and colleagues. Items are rated on a six-point Likert scale. The instrument has been validated in different countries and languages.

Table 1

Nineteen values of the Portrait Value Questionnaire Revised10

In addition to descriptive statistics, t tests were used to compare physicians’ value profiles depending on whether or not they used risk-relative standards. Missing values were deleted pairwise. Significance was assigned at the 5%-level.

Results

Among the 637 participants, a majority practiced in hospitals (84.5%, n=538), while only a minority worked in a specialist practice (15.7%, n=100), family practice (3.8%, n=24) or in another field (6.4%, n=41). Most of them worked full time (72.2%, n=460), with an average career duration of 20.95 years (SD=8.279). There were more male participants (65.5%, n=417) than female (34.1%, n=217), with an overall average age of 48.24 years (SD=8.123). In terms of medical specialties, those most frequently represented were internal medicine (30.5%, n=194), anaesthesiology (15.1%, n=96), psychiatry (11%, n=70) and intensive care medicine (8.8%, n=56). The numbers of participants with missing data were as follows: risk-relativity general item (n=30); chemotherapy vignette (n=4); assisted suicide vignette (n=21); value item (n=47); no missing values for the Portrait Value Questionnaire Revised.

General and case-specific attitudes toward risk-relativity

On the generally formulated item, the majority of physicians indicated that the severity of consequences of a medical decision was rather or very relevant for their DMC evaluation (72.6%, n=463). By contrast, analysis of the case vignettes showed that 65.9% (n=420) in the chemotherapy vignette, and 56.5% (n=360) in the assisted suicide vignette refrained from a risk-relative standard and applied equally stringent criteria (table 2). Almost all physicians who stated that the consequences are not at all relevant for DMC evaluations on the general item also indicated in the vignettes that they would apply equally stringent standards (chemotherapy: 92.7%; assisted suicide: 85.5%). In contrast, only half of those who regarded consequences as very relevant for DMC evaluations (on the general item) set higher standards in the case of treatment refusal (chemotherapy vignette; 43.4%) or in cases where the patient demands assisted suicide (assisted suicide vignette: 48.5%). The other half of participants refrained—contrary to their general attitude—from a risk-relative standard, and applied equally stringent criteria (chemotherapy: 55.4%; assisted suicide: 51.5%). Only a few indicated that they would apply higher standards if the patient consented to chemotherapy (chemotherapy vignette option 1; 0.9%, n=6), and therefore, this group was excluded from further analyses (table 2).

Table 2

Cross tabulation: General and case-specific attitudes towards risk-relativity

A comparison of the two consecutive vignettes shows that 43.9% (n=280) indicated that they would apply equally high standards in both vignettes (same standard for treatment consent, treatment refusal and assisted suicide), while 17.5% (n=112) indicated that they would apply risk-relative standards in both vignettes (higher standard in treatment refusal than in treatment consent, and an even higher standard in the case of assisted suicide). Another 17.3% (n=110) indicated that they would apply equal standards in the chemotherapy vignette and risk-relative standards in the assisted suicide vignette (same standard for treatment consent and treatment refusal, with a higher standard for assisted suicide). Another 12.6% (n=80) indicated that they would apply risk-relative standards in the chemotherapy vignette and equal standards in the assisted suicide vignette (same standard for treatment refusal and assisted suicide, but a lower standard for treatment consent).

Personal stance on assisted suicide

Although in the minority, some physicians did state that they would have to be personally convinced that assisted suicide was the best option available to the patient as a criterion for deeming that patient competent (15.9%, n=101; see table 2).

Relation to personal values

A quarter of all physicians indicated that their own set of values rather or very much influences their DMC evaluations (26.1%, n=166). In contrast, 22.4% (n=143) said that their own values had no effect at all.

With regard to physicians’ values, exploratory mean group comparisons of the answers in the vignettes yielded the following (table 3): In comparison to those physicians who applied equally stringent criteria, physicians who used a risk-relative standard in the chemotherapy case scored significantly higher on the values of achievement, power-resources and face, and significantly lower on conformity-rules and universalism-concern. With regard to the assisted suicide vignette, physicians with a risk-relative approach scored significantly higher on conformity-interpersonal, and significantly lower on hedonism, in comparison to those who applied equally stringent standards. Furthermore, those who said that they must be personally convinced that assisted suicide is the best available option returned lower scores on the value of hedonism in comparison to those who refrained from such a standard. Correlation analysis between the general risk-relativity item and value scores yielded no significant results.

Table 3

Group mean comparisons (t tests): Personal values and case-specific attitudes

Discussion

The aim of the present study was to explore the relationship between physicians’ attitudes towards risk-relativity and their personal values. The findings address the complex issue of risk-relativity from an empirical perspective, and point to the potential impact of healthcare practitioners’ values in DMC evaluations.

In terms of risk-relativity, the obvious discrepancy between physicians’ general and case-specific attitudes is noteworthy, especially in those who demonstrated a general attitude in favour of a risk-relative approach. A high proportion of those who said they would evaluate DMC with due regard to the consequences of a decision refrained from such an attitude in response to the specific case vignettes.

In the case of the chemotherapy vignette at least, this may be explained by referring to the notion of asymmetrical competence,12 the observation that while a patient may be competent to consent, they may be incompetent to refuse the same treatment. Such asymmetries are likely to occur under a risk-relative standard since the severity of consequences often diverges with treatment consent or refusal. The discrepant findings may result from an unequal manifestation of this asymmetry, which is supposed to be stronger in the vignette than in the general item because, in the vignette, the different alternatives are listed next to each other. It may therefore be that the appeal of a risk-relative standard becomes less intuitive, or even counterintuitive, as soon as the asymmetry becomes evident.9

It is not our intention to take a position for or against risk-relativity or asymmetrical competence; we wish only to show that the ambivalence around this issue in the scientific literature can also be found in clinicians,13–15 and that approaches to risk-relativity may differ according to the framing of the situation.

Although there is no comparable set of options for consent or refusal to the same treatment in the assisted suicide vignette, there is still an explicit comparison of alternatives that frame the situation differently, in contrast to a situation where the two decisions are separately presented and the standards are not relatively but absolutely determined.

In general, framing effects applying to the vignettes are interesting not as limitations to the study but rather as another sort of bias that needs to be critically assessed from a moral standpoint. Is it, for example, right to apply different standards in terms of mental abilities just because one has formed a particular view of the patient because of how the situation is framed?

Despite the obvious progression of the severity of consequences—at least from a medical perspective—from treatment consent, to treatment refusal, to assisted suicide, a third of physicians are not consistent in applying a risk-relative standard. Within this progression, there are physicians who only raise the standard when it comes to assisted suicide, and others who raise the standard when the patient refuses treatment, continuing to adhere to the higher standard in respect of assisted suicide. These findings suggest that there is something more at stake than the quantifiable severity of consequences, as qualitative aspects also appear to play a role. Moreover, there would appear to be individual differences in the perception of those qualitative aspects. Some physicians lump together treatment consent and refusal, separating them qualitatively from assisted suicide; others see no qualitative difference between treatment refusal and assisted suicide but distinguish them qualitatively from treatment consent. Taken together, these results strongly indicate that DMC evaluations are far from independent of physicians’ attitudes and values.

This view is additionally supported by the responses to item 3 of the assisted suicide vignette. Although in the minority, some physicians said that they must be personally convinced that assisted suicide is the best option available to the patient as a criterion for deeming the patient competent. Certainly, physicians are allowed to have different attitudes towards assisted suicide, and to refuse to offer assistance. However, it seems unduly paternalistic to deem the patient incompetent because of one’s personal conviction that assisted suicide is not a good option.9 In this case, a physician’s value judgement directly and deliberately pertains to the outcome of the patient's choice, and there is agreement that DMC evaluation should never be based solely on the decisional outcome but should rather be concerned with the decision-making process.1 It remains to be explored whether such effects also exist in less controversial situations or decision-making contexts.

A closer look at physicians’ values reveals that specific types of value relate to the use of risk-relative standards, and the results suggest that these relations differ with the particular situation: the values relating to a risk-relative evaluation in the chemotherapy vignette were not the same as those in the assisted suicide case. This case-specificity may also explain why there are no significant correlations between value scores and the general risk-relativity item.

Regarding consent or refusal to chemotherapy, those physicians who applied a risk-relative standard (ie, set higher standards in terms of mental abilities in the case of treatment refusal) were characterised by relatively high power and achievement values, which serve self-enhancement with a focus on social esteem.

Persons with high achievement values emphasise the active demonstration of competence or the pursuit of success as judged by the normative standard in a culture, whereas persons with high power values emphasise the attainment or preservation of a dominant position to obtain social approval.11 In terms of power values, risk-relative evaluations have been shown to be prevalent specifically in those physicians who strive for maintenance and protection of their own prestige, and for control over events, through their social and material resources. Although there is no significant effect with regard to the subtype power-dominance—the power to constrain others to do what one wants—the results may nonetheless be seen to support the concern that risk-relativity is used to introduce unjustified medical paternalism through the back door. This suggestion is grounded on the assumption that those physicians who strive for power, prestige and socially acknowledged success within their profession may see their personal values especially threatened if patients refuse a medically indicated treatment, and are therefore more likely to assess DMC as risk-relative to raise the standard for deeming the patient competent in cases of treatment refusal.

By contrast, physicians who strongly emphasise equal opportunity and equal treatment for all—a highly self-transcending value—tend to refrain from risk-relative standards, applying equally stringent criteria regardless of the decision. The same is true for those physicians who value conformity to laws, rules and authority, as if the use of equal standards were seen as the right or expected way to assess DMC.

Concerning assisted suicide, hedonism plays a role here to the extent that those who place high value on pleasure also tend to apply equally stringent standards in both decisions—against chemotherapy and for assisted suicide. This may be explained by a strong empathy for patients’ wishes to avoid any enduring suffering by ending their own lives. For this reason, they may choose not to raise the standard for deeming a patient competent in the case of assisted suicide. Additionally, these physicians are less likely to say that they must be personally convinced of the appropriateness of assisted suicide as a criterion for deeming the patient competent.

On the other hand, those physicians who emphasise restraint in respect of actions or inclinations that upset others are more likely to apply risk-relative standards, as if the use of equal standards in the case of assisted suicide was socially undesirable, likely to upset others, and therefore a threat to the values of those physicians.

While the results of this study indicate that risk-relativity may indeed be problematic to the extent that it introduces unjustified medical paternalism, it would be premature to reject risk-relative standards solely on the basis of these empirical findings—first, because the appropriateness of risk-relativity depends primarily on the conceptualisation of DMC; and second, because the present findings are preliminary, further studies would be needed to replicate the present findings, with regard to other kinds of medical decisions as well. To overcome the limitations associated with survey studies, it may also be worthwhile to deploy other research methods that account better for clinicians’ actions in real life.

From an ethical standpoint, it seems important to consider the moral status of the influence exerted by physicians’ values. Is there, for example, a difference between deliberately taking one’s personal stance on assisted suicide as a criterion for DMC and being more implicitly driven by one’s personal inclinations? Does it make a moral difference whether self-enhancing or self-transcending values impact on capacity evaluations? And what about different sorts of self-enhancing values—does it, for instance, make a difference whether a judgement is influenced by hedonism as distinct from a striving for power? Where should we draw the line in judging whether an influencing factor is morally permissible or not?

It further remains in question how best to handle these physician-specific factors. Since a total ban on such influences seems impossible, we propose that healthcare practitioners’ awareness of the impact of their personal values should be heightened, and that self-reflection should be encouraged with regard to the moral appropriateness of these influences. The fact that a quarter of participants in this study did not appreciate the potential impact of their values highlights a need to better sensitise physicians in this regard.

Ultimately, the evaluating physician must justify his or her own judgement, thereby also taking his or her own values into account, and make it intersubjectively comprehensible.

Conclusion

The inherent normativity of DMC is of concern for theorists of ethics and others who seek to articulate appropriate criteria in this context and for every clinician who is involved in DMC evaluations. Though guided by existing standards, capacity judgements are in the end discretionary, as the evaluator alone eventually determines whether or not it is legitimate to intervene on paternalistic grounds.

Such judgements necessarily involve values which render them less objective and more susceptible to external and potentially inappropriate influences. It has been shown that such influences are not always deliberate but evolve tacitly from physicians’ personal inclinations and values, affecting the stringency of standards required for DMC, including in some cases the use of risk-relative standards.

This evokes concerns about arbitrariness or even undue and disguised paternalism. At the same time, it seems difficult to totally circumvent any influence of physicians’ personal values on DMC evaluations and final competence judgements. It remains to be asked to what extent such influences are morally permissible, and at what point they clearly signal unjustified paternalism.

There may be no other choice than to accept that, within the evaluation, there is always a personal bias that renders the competence judgement specific to the patient and to the dyad of patient and physician.

Further research is needed to replicate and extend the empirical findings to other medical situations, and to other aspects of DMC evaluations, and to reflect on the moral appropriateness of physicians’ personal values within those evaluations.

Acknowledgments

The present study was conducted in cooperation with the Swiss Academy of Medical Sciences. The authors thank all study participants, co-applicant Bernice S Elger, Shalom H Schwartz and the advisory board: Paul S Appelbaum, Susanne Brauer, Mike Martin, Julian Mausbach, Christine Mitchell, Michelle Salathé, Egemen Savaskan, Christian Schwarzenegger and Armin von Gunten.

References

Footnotes

  • Contributors HH drafted the article. It was critically revised and approved by HH, MT and NB-A. All authors were involved in the study design and survey construction. HH and MT did the data collection, and HH conducted the analysis.

  • Funding Swiss National Science Foundation (grant no. 406740_139294).

  • Competing interests None.

  • Ethics approval Swiss Cantonal Ethics Committees.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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