Abstract
Following the previous general discussion of autonomy in philosophical and ethical theory, I will now turn to medical ethics, and set out how the principle of respect for autonomy has been interpreted and elaborated in that field. In standard works and textbooks on medical ethics, ‘autonomy’ is generally understood as the patient’s right to self-determination within the context of medical and research practices. As mentioned earlier, this right to self-determination is primarily a negative right to non-interference: the right to make decisions concerning one’s own life for oneself without being controlled by others. The principle of respect for autonomy thus functions as a moral rule that protects patients from unwelcome interference by physicians and other health care professionals and has become a principle that guides interactions between patients and care givers. Assuming this interpretation, the medical ethical literature discusses various aspects of and problems related to patient autonomy. Who has this right to self-determination? How can we make sure patients’ rights are respected? Can anything justify interference with these rights, and if so, what? What constitutes a free or autonomous choice? When is a person incapable of making such a choice, and how can his rights be respected when he is unable to exercise them?
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References
The report of the President’s Commission on health care decisions and informed consent was published in 1982, the same year in which Childress’ Who should decide, paternalism in health care was published. A year later Sartorius published a collection of essays on paternalism. Faden and Beauchamp’s History and theory of informed consent was published in 1986, the same year as VanDeVeer’s Paternalistic intervention and Feinberg’s Harm to Self
As we have seen, this is one of the arguments used to explain the value of the right to autonomy in general
It remains necessary, however, as a separate condition for autonomous actions in general.
For an analysis of the concept known as the ‘care of a good caregiver’, see van der Burg et al. 1994.
It seems as if the legal climate in the United States has contributed substantially to the tendency of physicians there to exhaustively list all possible risks of a procedure for the purpose of avoiding litigation, instead of for the purpose of informing their patients in a meaningful way.
Theoretically, an appeal to reason can and must be distinguished from an appeal to emotions, although this can prove difficult in practical situations.
In this context, it is interesting to observe that the classic role of the patient seems to be slowly shifting. A ‘virtuous’ patient used to be obedient and submissive; lately, however, the patient is expected to be self-determined and self-assured. A patient that was once labelled non-compliant might now be called autonomous (cf. Donovan & Blake 1992, Holm 1993).
In the third edition of their book, Beauchamp and Childress still treat informed consent and shared decision-making as two distinct entities. In the fourth edition they state that “by viewing informed consent as a temporal process, we can avoid the model of mutual decision-making and the model of a single event” (1994, 143)
If this is the way proponents interpret the ‘outcome* standard, their test for competence (determined by good reasoning or rational thinking) can be compared with establishing a person’s competence to drive a car by looking to see whether he will wind up in the right place.
Risk must be understood as including the chance of harm occurring, the seriousness of this harm and the reversibility or irreversibility of this harm.
I will not explore the issue of decision-making for incompetent patients in great detail, because it would take me too far from my central subject, autonomy, and because it is such a complex issue that it deserves separate study.
Studies indicate that (family member) surrogates correctly predict patients’ treatment preferences in 60–70% of cases (Hare, Pratt & Nelson 1992; Mattimore et al. 1997). According to some studies, they do not even do any better than random chance would (Suhl et al. 1994). Physicians do worse than family members (Seckler et al. 1991, Ouslander, Tymchuk & Rahbar 1989). Though family members do indeed appear to be most knowledgeable about the patient’s preferences, they are nevertheless mistaken in a significant number of cases.
One possible way to ameliorate this problem is by drawing up a ‘values history’ in which, in addition to the articulation of the patient’s advance directives, his values are explicitly identified and explained (Doukas & McCullough 1991).
An interesting and important discussion relevant for the validity of advance directives is that of (the continuity of) personal identity, for instance in the process of becoming demented. See Rich 1997, Newton 1999.
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© 2002 Springer Science+Business Media Dordrecht
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Schermer, M. (2002). Autonomy in Medical Ethics: Issues of Informed Consent. In: The Different Faces of Autonomy. Library of Ethics and Applied Philosophy, vol 13. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9972-6_2
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DOI: https://doi.org/10.1007/978-94-015-9972-6_2
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