Christiane Burmeister

Within debates on the epistemic preconditions of patient autonomy, scholarly attention has focused predominantly on the scope and weight of cognitive competencies, while the role of doxastic attitudes towards medical information have remained comparatively underexplored. Clarifying this issue is, however, of considerable importance when dealing with patients who, though competent and properly informed by the healthcare professionals, withhold belief in the medical facts presented to them. Are such self-imposed false believes compatible with autonomous decision-making and therefore demand respect, or do they undermine its epistemic foundation? Discussing two basic concepts of “understanding” as well as the resulting moral impasse between paternalism and arbitrariness, we propose a new direction of inquiry along two lines: First we interrogate a tacit assumption underlying the very notion of “self-imposed false beliefs” by discussing the question “Can we believe at will?”. This discussion yields a promising account that emphasizes the importance of reasons-responsiveness, shifting the focus from the belief itself to the process of belief formation. We conclude that not the truthfulness or falsity of patients’ beliefs is key but by the procedural quality of their development. By drawing on the Elaboration Likelihood Model, we are invoking psychological research that supports this claim. Secondly, in order to transfer these insights to the theory and practice of medical ethics, we distinguish two notions of autonomy based on their functions as (1) ideal philosophical concept and (2) basic status designation in real life. The paper argues that in the first realm the notion of reasons-responsiveness informs our assessment of false beliefs and strategies to enhance the “understanding” part of autonomy, entailing limited positive duties for healthcare professionals. At the same time, appealing to the relevance of a basic concept of autonomy in the realm of legally binding decisions we argue that the strong duty of non-interference with competent patient’s decisions must prevail.

Definition of the problemMedical and nursing care often takes place within complex organizational structures that comprise numerous facilities at numerous locations. We introduce an interactive ethical concept, designed in cooperation with the diaconal foundation BruderhausDiakonie Reutlingen and the International Centre for Ethics in Science, University of Tübingen, to address the particular needs of such organizations.ArgumentsTherefore we portray the interactive Nijmegen Model which combines an ethics committee located at the management level and situational ethical case deliberations on the ward in order to bring together two indispensable ways of ethical reflection in organizations: “top-down”/“bottom-up”. We illustrate the challenges of implementing the said model into the organizational construction of the BruderhausDiakonie and how to address these by means of conception and implementation.ConclusionConsidering the implementational challenges that we encountered, the Nijmegen Model needs to be enhanced by introducing a link between the committee and the case deliberations. We delineate the basic elements and the requirements for such a position while reporting our initial practical experience with this model.