how much pain or discomfort may be discounted against future benefit, lie outside
that area of expertise. The expertise in these matters, and hence the authority, lies
with the person who has to take the decision. See also the fourth reason below.)
The second reason is located in the idea of aperson.Most human beings are
persons and most persons are human beings, but the terms do not have the same
meaning [1]. A human being is a member of the biological specieshomo sapiens
sapiens;aperson is a moral agent who has plans and purposes and the capacity for
free choice. From the point of view of personhood, all persons are morally equal in
as much as there is no inherent reason for preferring one person's plans and
purposes to another's. It is not always possible, of course, for all persons to pursue
all their purposes. These may well conflict and there may be a need for mediation,
compromise, negotiation and accommodation. But such procedures do not ignore
aperson's moral agency. On the contrary, they only make sense when they are
addressed to an agent as an agent.
Disregarding a patient's right to consent to or to refuse treatment ignores the fact
that the patient is an agent and assumes that your plan to treat a patient in a
particular way is the only plan that matters. It is, in Kantian terminology, to treat
the patient as a means to an end and not as an end-in-herself [2]. It, therefore, fails
to accord that patient the respect and dignity due to a person whose moral
importance is as great as your own. And if you believe that your plans and choices
are important, then you must acknowledge that those of other persons are just as
important. To fail to do so is a failure of logic as well as a failure of morality.
The third reason why consent matters concerns human psychology rather than
logic or morality. A patient whose agreement to treatment has been sought and
obtained will feel empowered in a number of ways. Firstly they willownthe
treatment as an equal member of the team which has decided on it. They will be
acting, rather than acted on. Secondly, they will be less apprehensive about what
will happen since, if the agreement is real and not just stage-managed, they will
understand what is involved and its implications. And thirdly, they will have
retained control over their situation and, in situations where people are
profoundly vulnerable and probably distressed, this is clearly, and in some cases
literally, vital. They will feel, and be,autonomous.And since that term means no
more than being a free moral agent, a person, this second point connects us back to
the first. It is also important to see that this process of empowerment will go on
whether the patient agrees with the proposed course of treatment or whether they
refuse it.
The fourth reason why consent matters concerns what might be called fallibi-
lism. People can be wrong and, in particular, they can be wrong about what is good
for another person. The medical team is composed of experts in various fields, but
the only person who is an expert on what is good for me is me. The concept of
fallibilism applies here too, admittedly. I can be wrong about what is in my own
best interests; we all know that can happen. But I am less likely to be wrong about it
than someone else is and, in any case, if I am wrong I bear the consequences. If
someone else is wrong about what is good for me, I still bear the consequences. So I
have an incentive to get it right that they lack [3]. It is, therefore, vitally important
when decisions need to be taken about what will be good for me, that I take them,
even though I may need expert advice from others. What this means, in practice, is
The Critically Ill Patient 213