Understanding Autonomy in Family Medicine Ethics

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Understanding Autonomy in Family Medicine Ethics

• Dr. Yonah Yaphe
• Department of Family Medicine
• Rabin Medical Centre and
• Sackler Faculty of Medicine
• Tel Aviv University

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Objectives

• At the end of this presentation the learner will
• Know the meaning of autonomy in medical ethics.
• Know how to assess the elements of autonomy in a
  medical encounter.
• Value the preservation of patient autonomy while
  respecting other ethical principles.

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Case 1 Patient choices

• RS is a 55 y.o. divorced mother of 1
• Has severe COPD, frequent infections
• Is a heavy smoker for many years
• Returns for steroid injections with exacerbation
  of COPD
• Has longstanding depression with SSRIs
• Has a 25 year old son living at home

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Case 1 - continued

• Nurse T called the doctor for a repeat order for
  steroid injection for patient RS.
• At the weekly staff meeting Nurse T. complained
  Its not right, its not fair, it makes me
  angry.
• What are the ethical issues around the treatment
  of RS?

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Case 1 ethical issues

• the patients right to treatment
• the doctors duty to care
• the patients right to choose to smoke
• the doctors duty to inform and prevent harm from
  smoking and steroid therapy
• the doctors duty to distribute resources fairly

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The moral duties of the doctor

• The duty to help, cure
• The duty to promote and protect the patients
  health
• The duty to inform
• The duty to confidentiality
• The duty to protect the patients life
• The duty to respect the patients autonomy
• The duty to protect privacy
• The duty to respect the patients dignity

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The moral rights of the patient

• The right to high quality medical service
• The right to autonomous choice
• The right to decide
• The right to be informed
• The right to privacy
• The right to health education
• The right to dignity

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Principles of biomedical ethics

• Respect for autonomy
• Beneficence
• Nonmaleficence
• Justice

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Principalism A model of ethical decision making

• Making the best decision, in a given situation,
  all things considered

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Autonomy Definition

• Self-rule (Greek city-states)
• Autonomy is the ability to act in an independent
  manner
• self-governance, liberty, rights, privacy,
  individual choice, freedom of the will, causing
  ones behaviour, being ones own person.

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An autonomous person

• An autonomous person has
• LIBERTY (independence from controlling
  influences)
• and
• AGENCY (capacity for intentional action)

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Autonomous action

• Autonomous action exists in persons who act
• Intentionally
• With understanding
• Without controlling influences that determine
  their action

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Functional definition

• Is the patient free to think and act in the
  manner they usually would?
• Are there conditions of duress?
• Do they have information to act?
• Is their capacity to think and act reduced (by
  illness, drugs, injury)?

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Respect for autonomy

• Patients hold views, make choices, and take
  actions based on personal values and beliefs.
• Respect for autonomy respectful action, not
  merely a respectful attitude.
• Respect treating persons to enable them to act
  autonomously
• Disrespect attitudes and actions that ignore,
  insult, or demean others autonomy and thus deny
  a minimal equity to persons.

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Informed consent

• Autonomous choice More than agreement or
  compliance with proposal.
• Authorized through an act of informed and
  voluntary consent.
• Legally valid consent obtained from patients or
  subjects before proceeding with therapeutic
  procedures or research.

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Incompetence

• Inability to express or communicate a preference
  or choice.
• Inability to understand ones situation and its
  consequences.
• Inability to understand relevant information.
• Inability to give a (rational) reason.
• Inability to give risk/benefit related reasons.
• Inability to reach a reasonable decision.

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Paternalism

• The intentional overriding of one persons known
  preferences or actions by another person, where
  the person who overrides justifies the action by
  the goal of benefiting or avoiding harm to the
  person whose will is overriden.

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Weak paternalism

• An agent intervenes on ground of beneficence or
  nonmaleficence only to prevent substantially
  nonvoluntary conduct, i.e. to protect persons
  against their own substantially nonautonomous
  actions.

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Strong paternalism

• Interventions intended to benefit a person
  despite the fact that the persons risky choices
  and actions are informed, voluntary and
  autonomous.

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A central problem in biomedical ethics

• Does respect for autonomy of patients have
  priority over professional beneficence?

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Examples of conflicts with autonomy

• Contraception in a competent minor (patient
  cannot give consent yet autonomy is also
  compromised by bad outcome unwanted pregnancy)
• Informing authorities of serious illness (like
  seizures in drivers) in the interests of justice
• Patient refuses treatment that doctor and family
  believe is in their best interest (e.g.
  chemotherapy)

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Conclusions

• An understanding of patient autonomy is central
  to the understanding of medical ethics.
• It is applicable in daily practice of ethical
  medicine .
• Respect for autonomy may give rise to ethical
  dilemmas due to conflicts with other rights and
  duties.