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The Ethics of Deception in Caregiving: a Patient-Centered Approach

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The Ethics of Deception in Caregiving: a Patient-Centered Approach The Ethics of Deception in Caregiving: A Patient-Centered Approach by Rosalind Abdool A thesis presented to the University of Waterloo in the fulfilment of the thesis requirement for the degree of Doctor of Philosophy in Philosophy Waterloo, Ontario, Canada, 2015 © Rosalind Abdool 2015 I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii Abstract Deception is a central issue in bioethics. This emerges most clearly when considering ways of assisting individuals who are incapable of making their own decisions. Deception can be defined as purposefully misleading another to think that something one believes to be false is true. Philosophically, it is a crucial question whether deception should be considered morally indefensible or morally defensible in different clinical scenarios. My dissertation is a novel approach to considering deception in caregiving and provides a new method for assessing when deception is either morally defensible or indefensible. I ultimately argue that deception ought to only be used after considering several key morally relevant factors and that deception is prima facie morally indefensible. I argue that in very rare circumstances deception may be the most morally defensible alternative. These situations are often when a patient is significantly declining with no chance of recovery and there are no other plausible alternatives with a higher benefit-harm ratio in light of the morally relevant factors I explore. Other more rare circumstances include if there were significant chance of benefit to the patient, little chance of harm or risk and no other plausible alternative. I develop an organizational framework and a clinical framework to help guide caregivers through the decision of whether it is morally appropriate to deceive a patient in unique circumstances. The organizational framework is designed to consider organizational limitations and conditions from which health care administrators can formulate policies on this issue. I argue that constraints on deception include: mental capacity, compliance with treatment (when applicable) and risk of significant distrust, and that necessary conditions include: significant chance of recovery, disclosure and controlled environments. I further developed a case-based (patient-centered) clinical framework, Embedded Specified Principlism (ESP). ESP iii is a modification of Beauchamp and Childress’ Specified Principlism (SP) and it is both practical for the caregiving environment and provides comprehensive moral justification for determining when and when not to use deception. I consider several other bioethics models, including feminist bioethics and narrative ethics, and argue that these ought to be incorporated into ESP to highlight the importance of reducing stigma towards vulnerable/marginalized populations, fostering greater trust and other relationships between caregivers and patients and understanding the rich narrative of each unique patient. I further explore three major objections to traditional SP including arbitrariness, systematicity and casuistry and argue for two methods to reduce arbitrariness. On the basis of these arguments and the discussions of the morally relevant factors presented in my dissertation, I ultimately argue that deception in caregiving, although most often is morally indefensible, can be morally defensible in rare circumstances depending on the unique specifications of each patient’s experience. iv Acknowledgements I would like to acknowledge each of my family and friends for all of their love and support throughout my doctoral work. They have been instrumental in providing me with a strong personal foundation. I would like to express my deepest gratitude to my doctoral supervisor, Professor Patricia Marino, for her incredible support, knowledge and guidance. I am very grateful to have such a wonderful mentor both academically and professionally. I would also like to acknowledge the guidance of Professor Mathieu Doucet and Professor Christopher Lowry throughout my doctoral studies and especially for comments and feedback on my dissertation. I owe much thanks to both Debbie and Vicki for their incredible support and assistance navigating the doctoral experience. The faculty, students and staff of the University of Waterloo Department of Philosophy have also been a delight to work with. I have learned so much from everyone in such a positive and collaborative environment. Additionally, I would like to thank Professor Katie Plaisance and Professor Christy Simpson for taking the time out of their busy schedules to be my external examiners. I would also like to acknowledge the funding support I received through the Ontario Graduate Scholarship program. Finally, I must express my heartfelt thanks to my colleagues at the Centre for Clinical Ethics and at Hôtel-Dieu Grace Healthcare for always inspiring me and leading the way in striving towards excellence. Rosalind Abdool, University of Waterloo v To Inga Gurney, my greatest inspiration vi Table of Contents Abstract ..................................................................................................................................... iii Acknowledgements .................................................................................................................... v Table of Contents ..................................................................................................................... vii Introduction ................................................................................................................................ 1 Chapter 1 What is the Conflict? ............................................................................................. 12 Forms of Deception ............................................................................................................... 12 Intention ......................................................................................................................... 15 Consequence .................................................................................................................. 17 Cause .............................................................................................................................. 18 Naturalness (Expectations) ............................................................................................ 23 Current Philosophical Landscape of Deception .................................................................... 28 Beneficence .................................................................................................................... 29 The Autonomy Account ................................................................................................ 33 The Trust Account ......................................................................................................... 39 What is the Conflict? ............................................................................................................. 53 Conclusions ........................................................................................................................... 62 Chapter 2 Alternatives to Deception ...................................................................................... 64 Physical Restraints ................................................................................................................ 65 Advance Care Planning ......................................................................................................... 82 Absolute Truth-telling ........................................................................................................... 99 Conclusions ......................................................................................................................... 108 Chapter 3 Further Factors to Consider for Deception ....................................................... 111 Legal and Professional Constraints ..................................................................................... 112 Informed Consent ........................................................................................................ 112 Right to Choose / Right to Treatment .......................................................................... 113 Right to Personal Health Information (PHIPA) ........................................................... 118 Truth-telling ................................................................................................................. 122 Further Ethical Factors in Favour and Against Deception .................................................. 123 Deontological Factors .................................................................................................. 123 Consequentialist Factors .............................................................................................. 135 Virtue Ethics Factors ................................................................................................... 142 Conclusions ......................................................................................................................... 150 vii Chapter 4 Weighing and Balancing Factors ....................................................................... 152 A Process for Specification, Weighing and Balancing ....................................................... 153 Organizational
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