When Doctors Should Intervene: Ackerman's Ethics of Autonomy

Introduction

Terrence F. Ackerman's article "Why Doctors Should Intervene", published in the Hastings Center Report in August 1982, asks a central question: not only when doctors should intervene in patient decision-making, but also what is the appropriate relationship between a physician and his or her patient. Is the physician simply a provider of medical assistance? Or is there a parental role that the doctor must occasionally assume when he or she believes the patient's needs are not being met — due to a lack of information or an incomplete understanding of the patient's medical condition? Ackerman examines when doctors should intervene under such circumstances, while also explaining why intervention is occasionally both necessary and ethically defensible.

Ackerman suggests that a physician may need to treat a patient who does not fully understand his or her medical circumstances, and that this situation can arise in numerous ways. These circumstances include, but are not limited to, the patient's unwillingness to accept treatment for personal, psychological, or religious reasons, as well as a patient's family's desire to withhold or limit treatment — or to restrict the patient's knowledge of his or her own condition. Patient or familial guilt, depression, or even delusions can all give rise to a physician's legitimate concern that treatment is being compromised by a lack of understanding on the part of the patient or those responsible for making decisions on the patient's behalf.

Patient Autonomy in Modern Medicine

Doctors, like patients, operate in the real world rather than in the realm of medical textbooks. Ackerman notes that "patient autonomy has become a watchword of the medical profession" in recent years (14). In other words, doctors are increasingly reluctant to impose their own judgments upon patients' decisions about whether to accept treatment or even whether to live or die. Rather than "playing God," doctors are encouraged to act as facilitators of their patients' expressed wishes, rather than as agents who can withhold or administer treatment according to their own will.

Critical to a patient's ability to accept or reject treatment, however, is his or her capacity to have full understanding of the medical condition in question. Ackerman states, "knowledge of the patient's psychological and social situation are also necessary to help the patient act as a fully autonomous person" (14). Certain conditions may therefore impede a patient's ability to comprehend what he or she is actually suffering. A patient with schizophrenia, for example, who is convinced of his or her own immortality while in a delusional state, may not be able to fully grasp the urgency of a medical condition that threatens physical life.

Circumstances That Compromise Patient Decision-Making

Ackerman's framework identifies several categories of circumstance in which a patient's decision-making capacity may be genuinely compromised. Psychological impairment is one of the clearest: a patient whose perception of reality is distorted cannot be considered to be exercising autonomous choice in any meaningful sense. In such cases, the physician's duty to the patient's wellbeing may supersede the abstract principle of respecting stated preferences.

Beyond clinical mental illness, Ackerman also acknowledges that social pressures — including family dynamics and cultural expectations — can distort a patient's ability to make genuinely free and informed decisions. Depression and guilt, for instance, might cause a patient to decline treatment not out of a considered judgment about quality of life, but out of a feeling of being a burden to others. In these situations, the physician must assess whether the patient's apparent refusal of care reflects a competent, autonomous choice or a compromised one. The doctor's role becomes that of an evaluator of the conditions under which a patient's will is being expressed, rather than simply a passive executor of that will.