autonomy in healthcare ethics

https://doi.org/10.1007/s10730-018-9360-9, DOI: https://doi.org/10.1007/s10730-018-9360-9, Over 10 million scientific documents at your fingertips. [6] surveyed patients and family members about who should receive medical information and make medical decisions and how disagreements should be resolved. What Is the Physician’s Responsibility to a Patient’s Family Caregiver? Also, "Utility" – to promote more good than harm Together, the Principles of Medical Ethics and the Opinions of the AMA's Council on Ethical and Judicial Affairs make up the Code. The principle value of health ethics is the value of autonomy, which states that the patient has the right to refuse or choose their treatment. Autonomy is one of the central concepts in medical ethics. 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. 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. But how practical is informed consent? His conflict may cause discomfort for Dave and Dr. Barelle, but his decision is voluntary. Each of these principles is reviewed here. [6] also asked patients and family members to rank their values at the end of their or their loved one’s life. 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. 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.”. Furthermore, Dr. Barelle is in a challenging position as she is newly involved in Dave’s care and does not have a long-standing relationship to serve as a foundation for these difficult conversations. These results suggest that the values of patients and their family members are fairly closely aligned. As this selection of papers indicates, contemporary discussions of autonomy in the context of healthcare are rich and varied. Any notion of moral decision-making assumes that rational agents are involved in making informed... 2. 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]. Many professional ethicists recommend using four basic values, or principles, to decide ethical issues: Autonomy: Patients basically have the right to determine their own healthcare. This Special Issue then concludes with a discussion by Maura Priest in her paper, “Autonomy Centered Healthcare”, of the effects that the current approach to health insurance that is taken by the United States has upon the autonomy of both physicians and patients. Ethics needs principles—Four can encompass the rest—And respect for autonomy should be ‘first among equals’. 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. Healthcare professionals should protect patient autonomy and treat it as sacred as they do their own. It is a multidisciplinary lens through which to view complex issues and make recommendations regarding a course of action. Decisions made in situations of high stress, such as treatment decisions when there is little hope of substantial benefit, are difficult for all patients, families, and physicians. Principles of Biomedical Ethics. https://doi.org/10.1007/s10730-018-9360-9. John K. Davis also takes up the question of what counts as competence in his paper, “Dr. Applying ethical principles to the medical field has proven complex, as highlighted by James Childress in his writings on the complexities of adhering to respect for personal autonomy. Dr. Barelle has disclosed what aggressive care and comfort care would be like and Dave appears to understand the differences between treatment options. Beauchamp and Childress remind us that autonomy requires both “liberty (independence from controlling influences) and agency (capacity for intentional action)” and that liberty is undermined by coercion, persuasion, and manipulation . The ethical principle of autonomy is among the most fundamental in ethics, and it is particularly salient for those in public health, who must constantly balance the desire to improve health outcomes by changing behavior with respect for individual freedom. 4 Principles of Ethics for Nurses 1. The "four principles plus scope" approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. Respect patients as individuals (e.g., respecting their privacy by maintaining confidentiality and being truthful about their medical care). Autonomy is argued to be a central tenant to the ethical argument within medical law. Hamilton argues that it would violate a person’s informed consent to her treatment if she had been guided into it by the use of a “nudge”. Indeed, bioethicists often ascribe autonomy to a person with respect to, for example, her acts merely if she understood what she was doing when she performed them and was free from undue influence. Although it might be challenging to accept that Dave is choosing a course of treatment with a high chance of suffering for little chance of benefit, it is a reasonable decision to make. 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. Patients often wish to take their family members’ opinions into account when making medical decisions, as they would with many other important decisions. Family’s role in medical decision-making. Part of Springer Nature. Dave’s family has remained optimistic, confident, and encouraging; they fully expected him to pursue aggressive treatment. 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]. Beauchamp TL, Childress JF. Re-thinking the role of the family in medical decision-making. 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. Joseph T. F. Roberts, in his contribution to this Special Issue, argues in his paper, “Autonomy, Competence, Non-interference”, that the concept of competence is better placed than that of autonomy to play the anti-paternalist role that the latter concept often plays in contemporary medical ethics. In Dave’s case, his competence is not in question. Physicians are also bound by patient-physician confidentiality. HEC Forum Should she downplay the potential of aggressive care to better persuade the family to respect the patient’s wishes? Beauchamp and Childress (2012). 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. It is important for Dr. Barelle and Dave’s oncologist to confer so that they are both presenting the same options to Dave and his family. The Principle of Nonmaleficence Article  The question of the nature and importance of informed consent that Davis raises is taken up by Paul Hamilton in the fifth paper in this Special Issue, “A Republican Argument Against Nudging and Informed Consent”. 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. Thus, not only are bacteria and viruses (which are in the purview of medicine) of concern in the practice of health care… Resemblance to real events or to names of people, living or dead, is entirely coincidental. The physician-patient relationship is a fiduciary relationship in which the physician is obligated to act in the patient’s interests, with respect for the patient’s autonomy. Despite surgery, chemotherapy, radiation, and hormonal treatments, his prostate cancer has metastasized to his bones. Oxford: Oxford University Press. This approach might be appropriate in the initiation of bioethical discussion of a particular clinical case—and it might even lead to a resolution that all parties could agree to. Schäfer et al. 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. HEC Forum 30, 187–189 (2018). As Dr. Barelle continues to describe what aggressive acute care would entail over the next months and begins to probe deeper into Dave’s goals of care, Dave slowly confesses that he worries about aggressive treatment, states that it isn’t what he wants, and also says, “I’m not the hero type.” He goes on to express that he particularly values his independence and that he fears pain, suffering, impending loss of functioning, and loss of his autonomy. 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. The decision is acceptable as long as it is autonomous and the patient is aware of the risks and benefits of treatment. Autonomy Autonomy is recognizing each individual patient’s right to self-determination and decision-making. 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). ISSN 2376-6980. Even if their initial wishes are incongruent, patients and families usually have the same underlying values. 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. The author would like to acknowledge Dr. Raymond Hutchinson for his review of the manuscript, his edits, and his suggestions. Autonomy should be considered when it has features which relate to people, self determination or self governance, all of which are relevant to making healthcare decisions. Although there are some areas in which the … A patient’s independence is traditionally the highest priority in American bioethics [1]. Autonomy: In medicine, autonomy refers to the right of the patient to retain control over his or her … She will also have laid the groundwork for continued discussions as Dave’s cancer progresses and more decisions must be made. 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. Kimberly Hornbeck, MD, Kevin Walter, MD, and Matthew Myrvik, PhD. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA. In this case, Dave has elected to make his decision based on the wishes of his family. The autonomy of the patient has triumphed, in legal terms at least. autonomy [aw-ton´o-me] 1. the ability to function in an independent fashion. This allows for accountability and free will, with all the goods and burdens that it carries. American bioethics circumscribes the role of others who might influence the patient to make a choice that does not put his own wishes or best interests first. Both patients and family members ranked family, partner, children, and health in the top four, although in a different order. Doctors and health care personnel are legally required to disclose information about treatments to patients, and patients have the legal right to say “yes” or “no” to any treatment. Most respondents (78 percent) thought it was important for patients, their families, and their physicians to resolve disagreements jointly. 2. in bioethics, self-determination that is free from both controlling interferences by others and personal limitations preventing meaningful choice (such as inadequate understanding or faulty reasoning). New York, NY: Oxford University Press; 1994. 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. 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. Davis addresses the problem of patients who have made up their minds about a diagnosis or a treatment plan prior to meeting with their healthcare provider, having “researched” their medical condition on their own. In such cases, autonomy is known to generally increase job satisfaction. 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. 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]. He and his family have been presented with the relevant information to consider, and Dave appears to be making that decision without evidence of coercion by his family. It is thus hoped that this Special Issue will contribute to both the theoretical understanding of autonomy and to those debates in which it plays a role, and in which the contributors to this Special Issue have thereby engaged with. Katrina Ann Williamson and Christian J. Vercler, MD, MA, Moving Past Individual and “Pure” Autonomy: The Rise of Family-Centered Patient Care, Lee H. Igel, PhD and Barron H. Lerner, MD, PhD, Creating Value with the Patient- and Family-Centered Care Methodology and Practice: What Trainees Need to Know, Why, and Strategies for Medical Education, Anthony M. DiGioia III, MD and Pamela K. Greenhouse, MBA, “Nothing About Us Without Us”: Toward Patient- and Family-Centered Care, Evidence-Based Design: Structuring Patient- and Family-Centered ICU Care, Decision making/Patient and family centered care, Patient-clinician relationship/Patient, family-centered care. Dave’s physicians, however, now want to transition his care and incorporate hospice and palliative approaches to managing his illness. Whatever Dave’s ultimate decision, Dr. Barelle will have respected Dave’s autonomy and provided him and his family with all of the information needed for Dave to give informed consent for the next phase of care. volume 30, pages187–189(2018)Cite this article. 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. Access multimedia content about novel coronavirus. 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. 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. Autonomy, patient: The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. 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. Autonomy, also referred to as respect for persons, is a fundamental ethical principle that guides the clinical practice and research of mental health professionals. Beneficence is the second most important principle, stating that a practitioner should act in the best interest of the patient. Medical decision-making of the patient in the context of the family: results of a survey. 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. Ideally, for a medical practice to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and non-maleficence. Canterbury v Spence, 464 F2d 772 (DC Cir 1972). 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