Identity and authenticity in medical ethics | Charles Foster | TEDxHautLacSchool

Charles Foster is a Professor at Green Templeton College, University of Oxford, a member of the Oxford Law Faculty, and a practising barrister. He has been involved in many of the key cases in medical law, including the assisted suicide litigation in the House of Lords and the Supreme Court. He is the author and editor of many books, including Identity and Personhood in the Law, Altruism, Welfare and the Law, Medical Law: A Very Short Introduction, Human Dignity in Bioethics and Law, Choosing Life, Choosing Death: The Tyranny of autonomy in medical ethics and law, Depression: Law and Ethics, and Dementia: Law and Ethics. Charles Foster is a Fellow of Green Templeton College, University of Oxford, a member of the Oxford Law Faculty, and a practising barrister. He has been involved in many of the key cases in medical law, including the assisted suicide litigation in the House of Lords and the Supreme Court. He is the author of many books, including Identity and Personhood in the Law, Altruism, Welfare and the Law, Medical Law: A Very Short Introduction, Human Dignity in Bioethics and Law, Choosing Life, Choosing Death: The Tyranny of autonomy in medical ethics and law. This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at www.ted.com/tedx

[@Iggy-su2zu]

I wanted to express my sincere appreciation for your talk and highlighting the critical importance of respecting patients' autonomy and preserving their sense of identity and authenticity in medical decision-making. Your story about the father with Huntington's disease and his daughter who wished to know her own genetic status was a powerful example of the complex ethical issues that healthcare professionals face. The tension between respecting the patient's autonomy and duty to disclose medical information is a delicate balance that requires careful consideration of the patient's individual circumstances and values. As you highlighted in your talk, the principle of informed consent is essential to respecting patients' autonomy and preserving their identity and authenticity. Patients have the right to know their own medical information and make their own decisions about their healthcare and treatment options. Furthermore, your talk emphasized the importance of recognizing and addressing implicit biases in medical decision-making. Healthcare professionals must be aware of their own biases and strive to provide equitable care to all patients, regardless of their background or identity. Thank you for sharing your insights and personal stories on these critical issues in medical ethics. Your talk has provided valuable perspectives on the complex ethical challenges that healthcare professionals face, and I will certainly reflect on them as I continue my work in the field.

[@SDkbh-uq6ot]

Charles Foster brought up a really important question about patient care: who is the patient? Is it the person sitting in front of you at that moment, the person they present as most of the time, the person they want to be, or something else? This made me wonder about the concept of capacity, which is a patient’s ability to make and express medical decisions. Capacity is clinically determined based on whether a patient understands their medical situation, prognosis, treatment options, etc., and can make and communicate an appropriate medical decision without delusion while using reasoning that is consistent with their values. It is up to physicians to determine whether a patient has the capacity to make their own medical decisions, but if the physician is unable to do so, they may require an ethics committee consult or even legal intervention to help make their decision. After listening to this talk, I began to wonder whether the concept of capacity is truly ethical. Should doctors be able to decide if a patient has capacity, and should it even matter whether a patient has capacity? The answer to this question depends on who we decide the patient is. If we define the patient by who they are at baseline, then the concept of capacity seems quite ethical. However, if we decide that the patient is simply the person who presents to the clinic that day, then is it ethical to deem them incapable of decision-making? This gets especially tricky when considering a patient with Alzheimer’s disease. A patient with Alzheimer’s disease may present one day acting “normal,” but the next day seemingly dazed and confused. Inevitably, their disease will progress and their dementia will worsen to the point that their baseline is not what it used to be. And as Charles Foster stated, the patient may be perfectly content with that. So then if they are now expressing a medical desire that is different from the values they expressed before having Alzheimer’s disease, which patient do you listen to? Do you listen to their power of attorney who represents the person they used to be, or do you listen to the person that they have become? I do not know if there is a right answer, and there probably never will be. But at the end of the day, I believe the most important job of a provider is to treat each patient as a person, regardless of whether that person today is different from who they used to be.

[@hangslow4183]

Charles Foster asks one of the most difficult questions in regards to identity of a patient, who is the patient? I don’t think we are ever going to be able to know exactly who a patient is unless we are that patient. With that being said, I do think it is still appropriate to try to figure out and understand who a patient is. Approaching this question from an ethical lens I believe we can get closer to answering this question. Whether we are a doctor or another healthcare professorial there are ethical principles that must be upheld. Charles Foster mentions autonomy which gives the patient the freedom to choose freely, where they are able. This principle of autonomy certainly holds true for who a patient is. A patient/person’s identity is fluid and ever changing. It is not something that has to be rigid and unchangeable. Depending on the situation, who that patient is changes. This is seen throughout Charles Foster’s talk and his many examples of how a person changes in different circumstances. Another ethical principle that applies is non-malfeasance which says that we not intentionally create a harm or injury to the patient either through acts of commission or omission. In other words I like to simply say do not destroy hope. It is an ethical obligation for healthcare professionals to consider each patients situation and who they are at that moment in time. They must understand and accept the fact that a patient on a single day can be a completely different person another day. As Charles Foster says relationships have to be taken into account when trying to define who/what we are. By doing so we can work toward answering the question ‘who is the patient?’.

[@waterkingdavid]

I'd like to comment on: 1. The deep profundity and massive importance and implications of his question. 2. The apparent lack of interest in the question given the low viewership and comment rate. I honestly find it frightening to be living among so many with such an utter lack of interest in anything of great import. What's on telly tonight?!!!

[@user-sd2kq6ol6s]

I appreciate you vulnerability with the stories that you have shared. You mentioned in this talk how "if you treated my son's dyslexia, then you would kill my son." In regards to identity, yes treatment would change the identity of your son and inherently change the authenticity of who is it and how he is known to those in his inner circle. This, thought, raises the discussion of beneficence and maleficence. Treating your son's dyslexia would mean that Physicians have done good to prevent any more harm to what your son has been suffering with in the past. But would treating him, cause more harm that he has not suffered in the past? Harm that is psychological, emotional, or cognitive with this change in identity and the "who" of your son, now that a change would not be his true "authentic" self. In the "enhancement and therapy" discussion, the patient is the patient in BOTH pre and post operation. If they decide to take an enhancement pill or get a new hip from osteoarthritis, it is our duty as providers to respect their decision and provide all the care we can regardless of what has changed or where they are at in their life decisions. Yes, things will change but change is normal in life. If you can not be adaptable to change in a patient, then you won't have the proper empathy and compassion to be there for your patient as a provider. As humans we are more than just one thing in the current state or position. For example: if I am a married man who is out on a business trip for my company and I end up sleeping with another woman on this trip, I have cheated on my wife. Am I at home? No. Is my wife with me? No. Is my identity in that current moment a "business man"? You can say that. IN that current moment where the affair took place STILL be a married man with a wife, not solely a business man. Your identity goes beyond where your feet currently stand and its comical to have such tunnel vision. The same should go with the patient.

[@musicobsessed95]

I definitely agree with the points you raised regarding this Ted Talk. Especially in regards to healthcare, one needs to take into account a "holistic" view of the patient. Any healthcare provider at any level can cause irreparable damage to the patient in question- not only physically, but on the emotional/psychosocial level as well. However, this brings up an interesting scenario- although one must promote patient autonomy, if a patient's request wants to go against what a healthcare provider believes will be beneficial, would the healthcare team have to follow through? For example, if an individual does not want to receive a transfusion after experiencing a trauma and losing excessive blood, what should be done? Of course one wants to respect the patient's cultural views and autonomy as a decision maker in their own health. However, not wanting to cause harm and the blood transfusion being known to be highly beneficial and likely life-saving makes the action the physician/healthcare team should take a very difficult one to decide. In the moment of an emergency, how is one able to look at the "whole patient"? It becomes much more complex.

[@user-xf2tj9xd7w]

Charles Foster presents so much food for thought with the examples he provides in this TedTalk. For example, he mentions his son was diagnosed with dyslexia at the age of 6, he presents a woman who is dealing with anorexia and presents an individual who is monogamous with a brain electrode turned off and then tries to seduce her psychiatrist when the switch is turned on. I feel that all these examples provide such powerful examples and thoughts about which individual is the actual person. So many people will sit and think that conditions such as dyslexia or anorexia are illnesses that are ruining a person’s life and need to be cured. Sure, they could provide difficulties or nutritional side effects in the case of an anorexic person, but they also can be how someone identifies themselves and allow them to view the world in a whole new perspective. So instead of pushing people to feel like they need to be “cured” it needs to be presented as how can we help a person manage what they are dealing with so that they are safe but also comfortable in the way they live their life. Two more examples he provided also really intrigued me which were the examples of the Alzheimer’s patient with the advanced directive and the case of a man with huntingtins disease that won’t tell his pregnant daughter that she has the possibility to pass that on to her child. These points continue the idea of people change and a new individual even with a disease can arise from the same body but have a whole new perspective on life. Additionally, with the daughter of the father with Huntingtin’s disease who has no idea she could pass on this life altering disease to her child or herself have the disease presents the conundrum of whether doctors should be passing that information along or always must abide by their main patient’s wishes. He states that the law is starting to adjust in ways that can catch up to these ethical dilemmas that walk such a fine line of is what we are doing in this exact moment the right thing. Medicine and the law of ethics must work together to make sure that no matter what patients are being treated with the four pillars of ethics: Beneficence, Non-Maleficence, Justice and Autonomy. I really appreciated the perspectives Charles Foster provided because it illuminates that situations are always changing and that we as physicians must always be adaptable to different approaches of thought, treatment, and care for patients.

[@nickslaboden3492]

I would like to start this by saying thank you for sharing your stories of your shoulder dislocation and your son’s dyslexia. To be vulnerable in these situations is not an easy feat, but your stories helped to drive your point home in a powerful way. In this discussion you raise the question of “who” is the person, and how can we respect the decisions of others in an authentic way as healthcare providers. Respecting autonomy is something we discuss heavily in my medical ethics course. I believe the example of the anorexic patient is a good example of what my “take-home” was from your talk. Although anorexia is detrimental to human health, the patient does not want to be “cured”. As a matter of fact, it seems that the patient is content in her current state of anorexia. As physicians, it is our job to respect autonomy; therefore, we should respect the patient’s decision. This being said, one could make the argument that by not doing anything, we are violating the principle of beneficence, or not promoting the good. I think this is a great example of why the informed consent model exists. With the informed consent model, we are not making any decisions for the patient. We are still respecting their autonomy and not violating the principle of beneficence because we are trying to promote good by informing the patient of treatment options. Your discussion of the dementia patient was brilliant because you’re right, is this still the patient? Is this patient of sound mind and body? As a physician it is our duty to assess whether sound mind or body is present and in this case I would have to say no. So, how do we maintain respect for the patient’s autonomy? We have discussed medical durable power of attorney in my ethics course, and I believe this to be our best option for maintaining this ethical principle. If the patient has not designated a medical durable power of attorney, then we can move to state laws that will dictate the hierarchy of who will take on this burden. In this way, we are promoting respect for autonomy and respecting beneficence. In closing, I would like to say thank you so much for raising these questions. There needs to be more awareness on this issue because this is such a deep question in medicine that comes up very frequently.

[@Chan-cy2ks]

This was a really interesting perspective on autonomy and identity by Dr. Foster. The concept of self and identity is one that we will never be able to fully encompass and define, and Dr. Foster gives great examples of this predicament. The ethics surrounding personal identity can be approached from several different perspectives, including medical, philosophical, psychological, and social. The medical and philosophical aspects go hand in hand, as the principle of personal autonomy means that each individual has the right to make decisions about their own life, including, but not limited to, their medical care, beliefs, and values. Dr. Foster ties this heavily into the social and psychological aspects of self, saying that our identity is largely composed of our interpersonal relationships and not just our perception of ourselves. The story about the patient with Huntington disease was a great example of this-the father, diagnosed with HD, declined his physicians urges to allow them to inform his pregnant daughter of his condition, as it confers a 50% chance that his daughter would also have it. Medical professionals have an obligation to their patients, but that’s where the question comes in of, who actually is our patient? Medical practice views self as the entity of a single individual and their beliefs, but how do we quantify that when people are ever growing and changing? There is also the principle of non-maleficence that comes into play here, which essentially means “do no harm”, because by withholding that information from the daughter, there is potential for more harm to her in the long run. This concept also comes into play with his example of conscious-altering medications or diseases (i.e. dementia)-which version is the “real” patient, and if the two different conscious versions have conflicting views/decisions, which one do we uphold? If a patient in a sound mind prior to developing dementia clearly states that they do not want medical intervention, but goes on to develop dementia, where we consider them to be in a not sound state of mind, do we oppose the principle of non-maleficence to respect the wishes of a previous version of the patient that declined intervention, or do we uphold the principle of do no harm and deliver medical interventions against the will of a former version of this person? It is the responsibility of a physician to assess whether a person is of sound mind or not, so is that responsibility in and of itself imposing upon a person’s right to autonomy? I don’t have the answers to these questions, and I think this topic is something extremely profound that as a society, we have dumbed down to something much more basic than it truly is.

[@LoveOneSV]

I’ve been thinking about ethical responsibility of medical students during their rotations. It is a double edge sword where on one hand student does not want to severe the relationship with the hospital but on the other hand they have an obligation to ensure the safety and well-being of their patients. This includes preventing and reporting any acts of mistreatment, abuse, or neglect that they witness. This applies regardless of whether the student directly witnessed the mistreatment or heard about it from a third party. However, reporting someone from an insider talk will almost guarantee the student being ostracized from the inner circle of providers. But at the same time, by knowing about patient mistreatment and not reporting it, they are failing to uphold the values of the profession and are putting patients at risk. Additionally, under federal and state laws, healthcare professionals are required to report suspected cases of abuse, neglect, or exploitation of vulnerable individuals. Failure to report such incidents can result in legal and professional consequences and also potentially ruin someone’s career. Although morally there is an obvious answer on how to deal with cases of abuse, the reality of circumstances is much more nuanced and complex. I do not think there is a one correct answer, but I wish there was one.

[@martinlopez4719]

I believe we are more complex than being just one thing. We were this person in the past, but it’s not set in stone we can change as well

[@DO.Dr.JM13]

I love to hear medical ethics explained from someone who is not too closely connected to healthcare. As a medical student when we are exposed to the ethical questions presented here, we often have a singular view of the issue at hand because we live and die by the Hippocratic oath and the idea of beneficence, we try to do no harm and heal our patients to the best of our ability. However, like some of the examples listed here, the road we take to cure a disease can often present with some unwanted side effects. As I am presented with more and more of these cases I cannot help but realize that this is why many hospitals have medical ethic boards that work as a team to determine which is the best course of action in difficult circumstances. By having so many professions working together it can be difficult to reach a conclusion of what is best, and a lot of time can be wasted in determining treatment while a patient may be running out of time. These ethics boards are incredibly necessary though in protecting the rights of the patients but also to protect the physicians from overstepping their jurisdiction in treating their patients. As a physician I would be tempted to say that what the person does after I treat them and get them back to the right state of mind and body is no concern of mine. This is where the key term and medical principle of autonomy comes into play. By neglecting the new state of the patient, I am in turn neglecting the autonomy of my patient even if they are not sure what choice they want to make. If I choose to ignore the changes that have taken place and refuse to change the way the patient is being treated, I can be removing the autonomy of who that patient really is and thus removing the justice of the treatment since both parties are not being treated equally. As I mentioned before, in most of our classes we only focus on getting the patient to the treatment stage and all the ethical obstacles that exist from when we meet the patient to when they have accepted and received treatment. However, by looking at this from an outside perspective we can see that the continuation of care is just as important as the treatment itself.

[@user-ub3df2qv3f]

I really appreciate this take on the definition of oneself and how nuanced and complicated that really is. It is very interesting how this definition of self affects personal autonomy and when we think someone is capable of being autonomous and when they are not. If we think, as was referenced in this talk, that humans are simply “billiard balls with hard definite boundaries”, we may lean more heavily on the idea of personal autonomy. However, if we view the individual as more fluid, morphing in different social and environmental scenarios, and being ultimately part of a larger whole, then we will likely favor collective well-being over individual autonomy. Clearly, we admit that individuals are, in fact, in some sense part of a larger whole, and as a society we set standards and rules to prevent individuals from harming themselves and others. This is an infringement on pure autonomy that we have deemed appropriate because the individual really is not completely atomistic. We know that the frontal cortex plays a large role in self-regulation and decision making. Other parts of the brain play regulatory roles in mood, cognition, and interpretation of the world around us. When we up or down regulate those parts of the brain, or regulation goes away, that may in fact be a more authentic version of that individual, for better or worse. So, who’s autonomy should we respect, the diseased version of the individual, or the healthy version? The example of the alzheimers patient with an advanced directive to not resuscitate is particularly striking to me. I had not previously thought about the diseased person actually being a completely new person who is happy and given the choice, might not approve that advanced directive. However, I think I may have thought along this very train of thought. My mother was diagnosed with schizophrenia when I was about 12 years old, and she left my father and I unexpectedly and was gone for several years. She now lives back in our hometown again but due to her psychosis, delusions, and paranoia, she refuses all treatment and does not even believe there is anything wrong with her. I have often found myself explaining to people that ask, that the mother of my childhood is gone. They are certainly not the same individual. The previous mother would never have left her family and would have accepted treatment in order to preserve herself in the identity which we had come to expect of her as wife and mother. However, the same principles of autonomy now prevent the previous self from returning. She has been determined to be mentally incompetent on one occasion and was forced to be on medication. The old self shined through for a moment and when she was deemed competent, she abandoned treatment, and the new self is wise enough not to get herself involuntarily admitted and treated again. She the autonomy of the pre-disease self is abandoned for the autonomy of the new distinct individual.

[@MedschoolMom]

Mr. Foster’s example of a patient with dementia is intriguing. As Mr. Foster asks, is the person who signed the advanced directive prior to developing dementia the same person now that their memories and associations that defined their identity are gone? Not exactly. If this new person appears happy and content with their life, is it ethical to honor the advance directive that requests no lifesaving treatments? Especially when something simple like the administration of antibiotics could easily resolve their illness? Mr. Foster suggests perhaps the new person who has emerged from the ashes of the old should be allowed to choose, rather than let their former identity decide. In the current legal climate, of course doctors are required to honor the advanced directive. But there is certainly room for argument that there should be exceptions in such cases where the identity of the patient has changed drastically from the person who signed the document initially.

[@user-vy9zf4yl2j]

Psichiatry and neoroligy

[@peggyharris3815]

This talk is a lot more interesting than the title implies.

[@user-wq9yx4bd9m]

The idea of not having complete control of ones surroundings and the world around them is different from being an autonomous being and what it means to have freedom of control. Although one may be unable to do everything possibly imaginable (as like when restricted on flying in an airplane), he was still able to have control his over his body and thoughts relative to the current reality around him. although he will still like every hum I would like to apply this principle by posing a thought; Is autonomy really present if a person has a deep brain stimulator or any other brain altering device or medication and is making decisions whilst under the influence of the external stimulus? I believe that there is more to a human being than just a biologically set level of brain chemistries and anatomy. If one of these processes is founded to be faulty and could be corrected with treatment, then this should be done and the now fixed human being is still an autonomous being.

[@Heelsandholster]

I teach health ethics and am intrigued.

[@otimjimmy5387]

Mrs Kristen Linton