As we know, respect for patient autonomy is a core principle in biomedical ethics. It recognizes a slew of patient rights, including their right to informed consent and their right to refuse treatment. In principle, it ensures respect for the patient’s informed decision, whether it agrees with the physician’s recommendations or not. And, in the case of disagreement between patient and physician, doctors reach a critical point and ask themselves, “do I intervene?” Some, on the principle of patient autonomy, choose noninterference, stepping back and giving their patient’s the freedom to make their own choice. But, does this truly respect their autonomy? In Terrance Ackerman’s article, Why Doctors Should Intervene, he argues that noninterference does not respect patient autonomy because it does not account for what he calls, the “transforming effects” of a patient’s illness.
Now, you might be thinking, if respect for patient autonomy places nonintervention at its core, Ackerman’s argument is counter-intuitive. However, it makes sense in practice. Take patient competency. As Ackerman explains, certain constraints caused by a patient’s illness alter their ability to make a fully autonomous decision. These barriers can be physical, cognitive, or psychological, such as depression, anxiety, or even simple misunderstanding. He gives multiple examples of patients who, due to some impairment, can no longer make a decision and need a surrogate decision maker. In these cases, it is clear that intervention is justified because these patients are unable to make an informed decision. However, does this truly violate patient autonomy if the right to autonomy is not there in the first place? From previous discussions based on the writings of Beauchamp and Childress, we know that a patient’s right to autonomy is revoked if they are marked incompetent. So, in these cases, interference does not really violate anything at all. Noninterference, however, would not be in the patient’s best interest.
Take the anorexia case presented for our midterm. Bear with me now, as I know many of us disagree on which actions are justified. However, if we look at the case in favor of force feeding on the principles of beneficence and nonmaleficence, we see that intervention was necessary to save her life and in a sense, to give the incompetent patient her competence again. Ackerman mentions that loss of control is one of the worst things for a patient, so in cases of incompetency, is it warranted to remove patient control on the onset in order to fully restore patient control later on? In the force feeding case, for example, is it justified to go against her wishes for a short period of time in order to restore her to a healthy state of mind in the future?
If this is not pulling on your moral heartstrings already, it gets even more murky when the patient is competent. Some fully-competent patients (in terms of an absence of a debilitating cognitive or psychological illness) still succumb to bad decision making. Often, we put blind trust in our physicians because we think they know best. As Ackerman states, “many patients relinquish their opportunity to deliberate and make choices regarding treatment in deference to the physician’s superior educational achievement and social status. (“Whatever you think, doctor!”).” If a doctor takes their word and simply decides without any further discussion, a form of hard paternalism and noninterference, they violate patient autonomy (in the sense that they violate their right to an informed decision). Sure, the patient makes the decision to trust their doctor, but it is the doctor’s responsibility to be skeptical of this blind trust – especially when the patient has not heard all of the details. Ackerman suggests that doctors should “seek to neutralize” the constraints (whether big or small) so they may be more autonomous in future decisions.
Overall, patient autonomy should be respected. However, it can be respected in unconventional ways. Sometimes that is accepting the patient’s informed refusal, like in this case, while other times it is intervening to ensure the patient is competent and qualified to participate in fully autonomous decision-making. This was an interesting read for me and I look forward to hearing your thoughts!
REFERENCES
Ackerman, T. (1982). Why Doctors Should Intervene. Hastings Center Report, 12(4), pp. 14-7.
Beauchamp, T. & Childress, J. (2001). Principles of Biomedical Ethics. Oxford University Press.
Thomas, J. (2009). Well and Good. Broadview Press, 4.
Hi Julia,
I really enjoyed your blog post and think you made some excellent points. With regards to the article you attached at the end of your post, when doctors are intervening and almost pushing patients into treatment, they don’t necessarily know the entire backstory of the patient and their reasons for leaving against medical advice. In agreement with the article, “in the end, my patient’s leaving was not about our [healthcare professionals’] therapeutic alliance. It was not about me at all. It was about her, the patient, as it should be” (Defilippis). This article clearly explains how patients come to the hospital with their own unique personal histories which greatly affect their character and behavior when it comes to either following or refusing medical advice and treatments. Specifically, when it comes to sensitive topics and getting patients to go along with what is best for them, it is important to take a step back and try to understand the situation not only as their physician, but as another human being. Thus, physicians should perhaps take on the added role of medical liaisons between the patients and the hospitals especially when the patient lacks family and comfort.
Work Cited:
Defilippis, Ersilia M. “When Patients Leave ‘Against Medical Advice,’” The New York Times. Jan 12, 2017. https://www.nytimes.com/2017/01/12/well/live/when-patients-leave-against-medical-advice.html?_r=0
Hey Julia! I really enjoyed reading your post and the extra article you added at the end. As is explained in the article you posted, it is important to be understanding not only to patient’s medical history, but to their personal histories as well. It may be frustrating for health care professionals when a patient wants to leave “against medical advice”, but if the patient understands the risks and consequences, ultimately I believe the decision is up to the patient. In Mappes and Zembaty’s paper, “Patient Choices, Family Interests, and Physician Obligations”, they describe a case where an elderly man has been paralyzed due to a stroke, but still deemed competent. The doctor advises the patient to enter a nursing home after leaving the hospital, but the patient wants to go home. However, his old and frail wife is the only person at home who could care for him, but his wife is not physically able to care for him. She desperately asks for the physician to step in and override her husband’s choice or to convince him to change his mind. Even though I believe that patient autonomy is important, especially if one is considered competent, the patient is not acting in a responsible way. Going home might be what he wants, but in this situation it is unfair to his wife who will only. The physician must decide whether or not to intervene. If you were the physician, what would you do?
Works Cited:
Defilippis, Ersilia M. “When Patients Leave ‘Against Medical Advice,’” The New York Times. Jan 12, 2017.
Mappes, T. A. & Zembaty, J. S. “Patient Choices, Family Interests, and Physician Obligations.” Kennedy Institute of Ethics Journal, vol. 4 no. 1, 1994, pp. 27-46. Project MUSE, doi:10.1353/ken.0.0065
Hi Laura! Glad you liked the article. I agree completely with your comment. Communication is important – especially in these challenging situations!
Hi Rylee! Thanks for your comment. If I was the physician, I would convince – or even require – that the patient accept help from a nurse in his own home. I think there is a lot of fear and anxiety associated with nursing homes and perhaps the patient is experiencing this. So, I would compromise. I know that in the reading he is opposed to having any kind of external assistance, but perhaps if he sits down with his wife, a counselor, and the physician, he will understand that he would be a burden and even a danger to his ailing wife and accept the external help. The physician has an obligation to act in the patient’s best interests – in this case, under the care of a nurse – and the wife’s physician also has to protect her patient with her heart problem – which would be worsened if she had to assist her husband at home.
Hi Julia,
First off, I really appreciate your HIMYM reference. Secondly, I do agree with you that overall patient autonomy should be respected. However, the case that you cited at the end of your piece about patients leaving against medical advice, makes it appear that many health care professionals may be losing sight of the big picture outside the white walls. I like that Dr. Defilippis brings up the burden and stressor that is convincing patients to help themselves as much as the doctors are. Doctors are taught that their job is to help patients and do what’s in their best interest but that involves a lot of subjectivity. The part where I feel competent patients lose their autonomy is when doctors focus on what’s in their best interest, not necessarily the patient’s best interest. No one knows you better than you and therefore the decisions you make should reflect your ideas, not your doctor’s. Doctor’s are well versed in medicine but not always in the combination of physical, mental, and psychological health.
Sources:
Defilippis, Ersilia (2017) When Patients Leave ‘Against Medical Advice’
https://www.nytimes.com/2017/01/12/well/live/when-patients-leave-against-medical-advice.html?_r=0