Patient decision-making: medical ethics and mediation

A review of medical ethics literature relating to the importance of the participation ofpatients in decisionmaking introduces the role of rights-based mediation as a voluntary process now being developed innovatively in America. This is discussed in relation to the theory of communicative ethics and moral personhood. References are then made to the work of medical ethics committees and the role of mediation within these. Finally it is suggested that mediation is part ofan eirenic ethic already being used informally in good patient care, and that there is a case for developing it further. Professor Gillon's reflections on the 20th anniversary year of the birth of the Journal of Medical Ethics reminded us that "the importance of sharing discussions about the shared ethical dilemmas between doctors and nurses"1 was stated in its first issue. This also contained the Revd Dr Wilson's article, 'Communication with the dying', in which the importance of shared discussions with patients was given equal stress: "communication is mutual ... it is as important to acquire skill in human relationships as in materia medica".2 Those of us who attended London Medical Group meetings at that time will remember the focus on the pioneer hospice work of Dr Cicely Saunders, or Dr Murray Parkes and others, where patient decision-making at the far edge of life was shown to be essential for holistic palliative care, yet recognised as being an ethically sensitive issue requiring great professional patience, compassion and understanding. Hence the purposeful ambiguity of the title of this present paper. Its immediate purpose is to contribute to the current discourse within the National Health Service (NHS) and medical profession about the importance of resolving the many problems that are becoming increasingly numerous within it regarding patient care, and patients' complaints for which mediation is becoming a recommended option.