10 Dec autonomy in healthcare ethics
Autonomy. He finally admits that aggressive acute care seems to him to be excessive and futile at this point but that he doesn’t want to let his family down by not “fighting.” He fears that his family thinks of hospice and palliative care as capitulating and “giving up.”. One might, for example, question just how much a person needs to understand about her situation and the effects of her proposed courses of action upon it in order to count as autonomous with respect to her decisions. When such difficulties arise, it becomes clear that no matter how far removed the practical discussions of what to do in a particular medical situation to respect the value of autonomy might appear to be from the theoretical analysis of this concept, they need a robust theoretical grounding so that questions such as this can be answered when they occur. Focusing on the strict definition of autonomy and failing to recognize an individual as part of a family leads to an incomplete understanding of decision making for informed consent [2]. 4 Principles of Ethics for Nurses 1. Ninety-three percent of respondents felt that both patients and family members should receive medical information; 70 percent of patients felt that family members should have a role in decision making, but only 54 percent of family members felt that they should. In order to best care for Dave, Dr. Barelle must consider how to respect both his autonomy and the role of his well-intentioned and loving family in his care. It requires physicians to respect patients’ autonomy by giving them the information needed to understand the risks and benefits of a proposed intervention, as well as the reasonable alternatives (including no intervention), so that they may make independent decisions. ISSN 2376-6980. Canterbury v Spence, 464 F2d 772 (DC Cir 1972). The phrase “first among equals” was used in this context by Gillon (2003). John K. Davis also takes up the question of what counts as competence in his paper, “Dr. Whilst these principles may serve to protect patients from abuse and give them an active role in their treatment, ETENE states, If he is comfortable with greater transparency, Dr. Barelle should discuss his values and hopes, as well as his family’s values and hopes for him, as a foundation for setting care goals—prolonging life or minimizing suffering, for example—during another appointment at which a family member is present. Dr. Barelle should discuss with Dave precisely which pieces of information he is comfortable having her disclose to his family so that she does not break physician-patient confidentiality in her attempts to advocate on his behalf. His conflict may cause discomfort for Dave and Dr. Barelle, but his decision is voluntary. Given this, he argues, a patient who was able autonomously to consent to her treatment but who becomes unable to continue to assess whether or not she could continue with it will lack autonomy with respect to her ongoing treatment. We invite submission of manuscripts for peer review on upcoming theme issues. But how practical is informed consent? Google and Premature Consent”. Dave’s family has remained optimistic, confident, and encouraging; they fully expected him to pursue aggressive treatment. Therefore, clinicians must be mindful of the potential for this dynamic and advocate for the patient to ensure that he or she feels free to make an independent decision. Family’s role in medical decision-making. It is both common and socially acceptable for a patient to consult family members in order to aid in decision making. He can provide insight into how his family would best understand the medical information, and they can discuss how to help his family understand his wish not to pursue aggressive therapy, even if he refuses to tell them directly. Kimberly Hornbeck, MD, Kevin Walter, MD, and Matthew Myrvik, PhD. Basic Principles of Medical Ethics Autonomy: People have the right to control what happens to their bodies. For Roberts, individuals should be granted rights against interference by others once it has been established that they are competent; that they can acquire knowledge, exercise instrumental rationality, and form a life-plan which they can revise as they see fit. PubMed Google Scholar. This, argues Hamilton, violates the republican freedom of the patients insofar as they are no longer free from the possibility of arbitrary interference by another—a position that has clear affinities with that of Roberts earlier in this Special Issue. The palliative care physician, Dr. Barelle, sits down alone with Dave to discuss his end-of-life wishes. Although it … Dave’s health is on the decline. Oxford: Oxford University Press. When an autonomous patient’s stated wishes and actions are not aligned, the physician must both respect the patient’s decision and keep his wishes confidential if he has asked her not to disclose them. Resemblance to real events or to names of people, living or dead, is entirely coincidental. These results suggest that the values of patients and their family members are fairly closely aligned. Autonomy Autonomy is recognizing each individual patient’s right to self-determination and decision-making. Having such a discussion does not mean that the clinicians come to a decision for the patient, but rather that they all agree on the available options and the potential risks and benefits of each in order to present a consistent interpretation of the current situation and the reasonable next steps. Yet, not everyone agrees that a theoretically-rich account of autonomy is needed to undergird the practical discussions of medical ethics where this concept has recently come to play a prominent role. Respect for Autonomy Autonomy, also referred to as respect for persons, is a fundamental ethical principle that guides the clinical practice and research of mental health professionals. Therefore, facilitating a discussion about Dave’s underlying values might be a strategy for Dr. Barrelle to generate concordance between him and his family. What should she do? Indeed, so dominant has it become that of the four principles of biomedical ethics that Beauchamp and Childress outline in their seminal Principles of Biomedical Ethics (respect for autonomy, beneficence, nonmaleficence, and justice) respect for autonomy can rightly be said to be the “first among equals”.Footnote 1 Unfortunately, despite the dominance of autonomy in medical ethics, the development of a theoretically satisfying account of autonomy that can play the role that it is often called to play in the practice of medicine has been challenging. Relational autonomy or undue pressure? Similarly, the Finnish National Advisory Board on Health Care Ethics - ETENE - (2001) cautions against concentrating almost exclusively on the principles of autonomy and self-determination. Medical Ethics? Davis’ and Hamilton’s concerns about the type of information that patients have access to and base their decisions upon is shared by Thomas May and Harold Grotevant. Autonomy is the idea that every person is in control of their own thoughts and actions and can be motivated by ‘internal’ forces like choice and reflection. Respecting patient autonomy thus includes respecting both how patients wish to make a decision and the decision made, even if the decision is to allow their family’s desires to supersede their own [4, 5]. Copyright 2020 American Medical Association. Health care ethics (a.k.a “medical ethics”) is the application of the core principles of bioethics (autonomy, beneficence, nonmaleficence, justice) to medical and health care decisions. Autonomy means "self-rule" and involves the right of an individual to make choices that may go against a physician's treatment advice concerning treatment, or non-treatment, of an existing health … Commentary 1, What Is the Physician’s Responsibility to a Patient’s Family Caregiver? Should Children be Asked to be Bone Marrow Donors for Siblings? Ethically, autonomy aims to protect individual choice, rights, and freedoms against the control of organisations, the state or other people. HEC Forum 30, 187–189 (2018). Even if their initial wishes are incongruent, patients and families usually have the same underlying values. Beauchamp and Childress remind us that autonomy requires both “liberty (independence from controlling influences) and agency (capacity for intentional action)” [2] and that liberty is undermined by coercion, persuasion, and manipulation [1]. A concern to combine the theoretical and practical discussions of autonomy also motivates Steven Weimer’s discussion in his paper, “Evidence Responsiveness and the Ongoing Autonomy of Treatment Preferences”. All Rights Reserved. Moreover, he argues, such patients are also not truly informed, for they are unable accurately to determine which sources of medical information they should trust, and they might fail to believe information that they are provided with. Despite giving informed consent, he continues to struggle with the conflict between his desire to avoid further aggressive therapy and his desire not to cause additional pain to his family by refusing treatment that they wish him to undergo in hopes of prolonging his life. It is even more difficult when the physician’s relationships with the patient and the patient’s family have not had time to develop. He is making his decision without undue influence from his family or clinician, and he has given his consent to proceed with aggressive treatment. The people and events in this case are fictional. 1. Re-thinking the role of the family in medical decision-making. Bioethicists often refer to the four basic principles of health care ethics when evaluating the merits and difficulties of medical procedures. Should Potential Risk of Chronic Traumatic Encephalopathy Be Discussed with Young Athletes? Laura Sedig, MD is a pediatric hematology/oncology fellow at the University of Michigan in Ann Arbor. To rectify this circumstance, Weimer provides a way to account for this temporal aspect of autonomy that is not only theoretically satisfying but which can be drawn upon in the practical debates of medical ethics. In her paper, “The Need for Authenticity-Based Autonomy in Medical Ethics”, White argues that it is only through drawing on the concept of authenticity that we can effectively address concerns that might arise in a medical context as to whether or not a person’s desires are truly her own (e.g., when a person’s medical decisions are highly unusual) and thus should be accorded the respect that is due to a desire with respect to which a person is autonomous. Healthcare professionals should protect patient autonomy and treat it as sacred as they do their own. These findings suggest that Dave might be taking his family’s wishes into account more than his family would want or expect, and that his family might wish to resolve the conflict with a discussion involving Dave and Dr. Barelle. The principle of nonmaleficence requires of us that we not intentionally create a... 3. The philosophical discipline of bioethics is not narrowly tied to medicine, but expands to cover medical anthropology, medical sociology, health politics, health economics, research, public health policy, and … In a medical context, respect for a patient's personal autonomy is considered one of many fundamental ethical principles in medicine . Article autonomy [aw-ton´o-me] 1. the ability to function in an independent fashion. The "four principles plus scope" approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. Glover states that patients should have the right to be allowed to make their own choices over what medical treatment they should receive. In the case of undue influence from family members, Dr. Barrelle would be obligated to follow the patient’s wishes after discussion with his or her family. However, it might also be the case that the thinness of this account of autonomy could preclude the making of any practical decisions even among persons who agree that autonomy is the primary value to be used to decide the case at hand. FORMAL ACCOUNTS OF AUTONOMY. Patient autonomy does allow for health care providers to educate the patient but does not allow … The autonomy of the patient has triumphed, in legal terms at least. Beauchamp, T. L., & Childress, J. F. (2012). Most regard autonomy as something of value, but many different explanations of its value are defended. Dave’s physicians, however, now want to transition his care and incorporate hospice and palliative approaches to managing his illness. And, of course, this selection reinforces the long-held view in political theory that a concern for the value of autonomy should be used to assess the merits of policy proposals, such as, for example, nudging or new methods of providing health insurance. Non-maleficence – to not be the cause of harm. Additionally, when a patient’s care is divided among multiple clinicians, it is ideal for all of the clinicians to discuss the case among themselves to minimize confusion for the patient and family. As a principle that can be readily turned into a process, the giving of ‘informed consent’ by a patient has become the surrogate measure of whether medical interventions are ethically acceptable. This selection of papers also shows that such discussions can be helpful in illuminating questions in medical ethics that arise as a result of new technology, either those that arise directly from it (such as, those generated by advances in genetic testing) or those that are generated more indirectly (such as, those engendered by patients’ access to vast amounts of information through the Internet). © 2020 Springer Nature Switzerland AG. Although the principle of autonomy is well established in medical ethics, while competent patients clearly retain the right to make decisions on their own behalf, in a practical sense patient’s interests are best respected by seeing medical decision making as a partnership based on mutual respect, communication, and information exchange. He argues that these patients are not truly competent—and so their decisions should not provide the bulwark against interference that Roberts argues competent decisions should be held to—for they are not deliberating well when they make medical decisions prior to seeing a healthcare professional. Beauchamp TL, Childress JF. A best result of this conversation would be that Dave and his family come to an agreement with regard to his future treatment. As patient advocates, it is imperative that nurses ensure that patients receive all medical information, education, and options in order to choose the option that is best for them. Journal of Medical Ethics, 29(5), 307–312. Autonomy is a term used to describe a person's or government's ability to make decisions, or speak and act on their own behalf, without interference from another party. Aveena Kochar, MD and Alia Chisty, MS, MD. 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