We define respect for autonomy as “[requiring] that autonomous actions not be subjected to controlling constraints by others” (Beauchamp and Childress, 107). At the core, it seems essentially unreasonable for a physician to disregard respect for autonomy as by this definition one would be “controlling” a patient in need. Where the lines begin to blur, though, is when you bring in the patient’s state of being to the table. A patient’s impediment to their ability to make autonomous decision can range from mental and physical capacity, emotional state, social and cultural limitations, among other things. These “various kinds of constraints can impede autonomous behavior” (Ackerman, 15). The question we ask is when is it okay for doctors to step in and override a patient’s wishes?
In previous cases we have studied, we see this dilemma quite often. For example, in our latest case we saw a 21-year-old anorexia patient who refused to be force-fed, even though she would likely go into cardiac arrest after a few days. Our patient, Amelda, seems to fit all the criteria for being considered mentally stable, minus the fact that she does not comprehend the full consequences of her decision not to be force-fed. The argument here was that she was determine incapable of making her own decisions without probable cause. This blurs yet another line between the patient-physician relationship of when a patient can be determined incapable of making his/her own choices. Amelda’s doctor and parents considered her inept to make sound decisions in this case, but had she gotten a second opinion, another physician may have disagreed. Different opinions from different physicians essentially causes human error when evaluating whether or not a patient’s autonomy should be rightfully violated.
Violating a patient’s autonomy leads to a slippery slope of violating the principle of informed consent as well. In Amelda’s case, when the doctors gave her a feeding tube against her will, her autonomy was violated as she did not explicitly ask for the treatment. In turn, this means that she did not give informed consent and that that principle was violated as well. Essentially, by not respecting a patient’s autonomy in the context of a given treatment, even when it is lifesaving, both informed consent and autonomy are not upheld in an ethical sense. While this could be considered a case by case basis, the principles and rights of a patient are all the same and it should be considered no different if a person refuses a cosmetic surgery or a lifesaving surgery. In any situation, a patient’s autonomy should be maintained despite the possible consequences due to the slippery slope that would quickly ensue if that right was not upheld. In the end, no doctor should not intervene in a patient’s decision to forgo or continue treatments; only give support and information to the best of their ability.
Works Cited:
Ackerman, Terrence F. “Why Doctors Should Intervene.” The Hastings Center Report 12.4 (1982): 14-17. JSTOR.
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. Print.
Thomas, John E, et al. “Case 3.3: Discontinuing Forced Feeding of an Anorexia Nervosa Patient.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 2014.
Hi Shelby!
I agree that patient autonomy is a very important ethical principle that should be respected in as many cases as possible. However, I do think there are some cases in which issues of beneficence or nonmaleficence may give the doctor leverage to act against the patient’s wishes. As you said, the situation becomes tricky when the patient’s mental state and competence are called into question. If a patient is deemed incompetent, it is the duty of the physician to act on his or her behalf in order to help and prevent harm to the patient. But is the line between competence and incompetence blurred? I have a couple issues with the force of Ackerman’s article, particularly when he talks about competence. He essentially states that for all patients with illnesses “the choice of goals is seriously hampered and subsequent decisions by the patient are not well founded” (Ackerman 15). While some illnesses, such as Alzheimer’s disease or dementia, may inherently impede cognition or decision-making, not all illnesses cause a patient to make unfounded decisions. I believe that his claim is far too generalized and that there are many patients that although they have illnesses, are more than competent to make their own decisions.
If incompetence is taken out of the picture and the patient is deemed to be capable of making his or her own decisions, I don’t know if a doctor overriding patient autonomy is ever fully justified. According to Dax Cowart, a man who suffered immense pain following severe burns in an explosion, “freedom, true freedom, not only gives us the right to make the correct choices; it also has to give us the right sometimes to make the wrong choices” (Cowart and Burt 17). Cowart begged his doctors to stop administering treatment and to let him die following his accident in order to eliminate the pain; however the doctors overrode his wishes, even after he was deemed competent. Although he is angry that the doctors denied his right to autonomous choice, he has stated that he is happy in his life now, happier than he thought he could be. Is his outcome a reason to justify doctors intervening, even when the patient is deemed fully competent? Or, as Cowart suggests, sometimes do we just have to let people make bad choices because it is their right to do so? I think that people, as autonomous beings, should have the choice to decide what happens to them. However, it is the duty of the physician to make sure not only that the patient is competent, but also to examine the true reasons why a patient may went to refuse treatment or not undergo a surgery. As stated in the article by Cowart and Burt, it is often compassion and persistence that help patients get better and help them make the most clear-headed decisions. Ultimately, I agree that patient autonomy is of the utmost importance; however I am not comfortable making the claim that autonomy always trumps the other major ethical principles of beneficence and nonmaleficence.
Works Cited
Ackerman, Terrence F. “Why Doctors Should Intervene.” The Hastings Center Report 12.4 (1982): 14-17. JSTOR.
Cowart, Dax, and Robert Burt. “Confronting Death Who Chooses, Who Controls?” The Hastings Center Report, vol. 28, no. 1, 1998, pp. 14–24.
I agree with you that patient autonomy overrules, ultimately. The physician should not intervene in the patient’s decision. However, I believe a physician can challenge a patient in their decisions. the relationship between the patient and physician should be a two-way street before the patient makes the final decision. They can express their opinions and what they think is best for the patient, even though a patient may disregard their thoughts. I believe by challenging the patient’s choices, the physician may facilitate the autonomy of the patient or help the understanding of the patient. Although the patient has the final say, the physician should provide all the information necessary and help the patient weigh the options. The patient should be confident and fully conscious to the decision.
The question of incompetence becomes more difficult. When the patient is not fully autonomous, the physician should include the family and make sure they are fully aware of the options. In this case, the relationship between the family and physician is a two -way street (perhaps a three- way street), with the consideration of the patient’s opinions.