Patient autonomy in medical decision-making

¶ … Patient Autonomy

The concept of patient autonomy, as opposed to medial paternity, is one that has gained much ground in recent years; "... about 30 years ago, issues began to appear that were difficult to solve using traditional ethics. New medical and reproductive technologies, research controversies, and a societal ethos that questioned all authority posed difficult questions." (Czaplyski, Larry, 2002)

At issue in this paper is the meaning and significance of patient autonomy and the way in which is relates to medical paternity. As the discussion will outline, the case for patient autonomy is not only ethically valid but also essential for the moral and practical balance in the medical profession. Underlying this view is the fact that the issue of patient autonomy does not exist in isolation or in the medical field alone - but relates to other issues and ethical problems in the society at large. These larger issues refer to various forms of control and authoritarianism which act against personal liberty and freedom.

The argument will centre on two imperatives. Firstly, that patient autonomy is an inalienable right and is ethically related to freedom of choice and freedom of speech. The second reason for upholding patient autonomy focuses on the fact that the practice of modern medicine has tended to become increasingly more clinical and mechanical and imposes itself on the patient through the force and status of science. This has resulted in an unhealthy patient-doctor relationship and the distancing of the patient and medical practitioner. In this respect patient autonomy is seen as not only ethically valid but as a necessary counterweight to achieve an open and balanced relationship between the patient and the health practitioner.

The concept of and motivation for patient autonomy is best understood by understanding the meaning of the term medical paternity. Paternity is a concept that is allied to a wider and predominantly contemporary problem, namely the world wide reaction against forms of control and dominance from persons, associations or groups that are not transparent and open in their dealings. The term paternalism carries with it many loaded meanings based on restriction and control, particularly pertaining to information. The term has been deconstructed in many spheres, including the field of medicine. This deconstruction aims at exposing the hidden layers of hegemony and biased authoritarianism that the term implies.

Although there may be disagreement on how to define the term "paternalism," there seems to be an origin of paternalism other than that from the physician which can affect the degree of autonomy which a patient can express. In my view, paternalism is a parental form of direction or order to the patient to the effect that "we know what is best, you may not understand it but follow what we say." This kind I think originates from institutions within our social or political environment. (Bernstein Maurice, 2004)

The definition of patient autonomy on the other hand counters the tendency of paternalism to dominate and control by insisting on "the right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient. (MedicineNet: Patient autonomy) more precise definition which hints at the complexities and possible ambiguities involved in the term 'patient autonomy' is the following:

Thus, patient autonomy refers to the capability and right of patients to control the course of their own medical treatment and participate in the treatment decision-making process. Today, case law and the courts define the legal limits of patient autonomy, usually framed under the rubric of informed consent. (Healthcare Ethics, 2004)

The idea of informed consent is an area that often arises in debates on patient autonomy. This term refers to the concern that the issue of autonomy must take account of those patients who are not adequately informed or knowledgeable, or who are not in a position to make decisions. This obvious and important point which, however, should not be allowed to obscure the central issue which is not the degree of patient autonomy but rather an essential element in the medical arena. A definition that points to the need for informed decision-making is the following:

good working definition of "autonomy" is "self-determining free choice." What distinguishes "choice" from mere appetite or desire is deliberation upon known, available options and their probable consequences, and a practical equilibrium of external pressures for and against those options.

Bradley, Gerard V. (1989)

Informed consent' is often a cause of dissention and ambiguous interpretations of 'patient autonomy." It should be made clear that informed decision-making is included as a necessary and implied part of the definition of patient autonomy in the present argument and that patient autonomy does not mean careless and uninstructed freedom.

In another sense informed content impacts on the present discussion in that informed content should be provided by the practitioner in order that the patient may exercise his or her personal choice. This bears on the fact that communication between the patient and the doctor or practitioner should be understandable and honest - with every effort made to enlighten the patient as to his or her options.

Even when patients have been informed of the possible consequences of medical intervention, they may not adequately understand what is involved. Natural intelligence, level of education, and vocabulary all may limit the patient's comprehension. To meet this problem, physicians try to put informed consent into "plain" English. Medical terminology is replaced by lay expressions in the hope of truly informing the patient... The requirement for informed consent is not satisfied by merely recounting risks and benefits to a patient, but by doing so in a way that is intelligible to a particular patient in view of his individual capacities. (Gunn, Albert E., 1991)

This point leads to the second imperative in this paper, namely that patient autonomy is also intended to create and enforce healthy communication between patient and health practitioner. Patients who are supplied with information and details about medical issues can avoid the possible fallacy of therapeutic privilege. This refers to instances "when a doctor decides for a seemingly capable patient that it is in the patient's best interests not to know certain information..." (Doing Right, 79) (Iatus, A. 2002)