The question that Ackerman presents at the beginning of the piece is something that I’ve pondered even before our class discussions. Does non-interference really respect patient autonomy? The answer is contingent on the situation. Time has a lot to do with how a patient absorbs, processes, and responds to a given situation. Humans are adaptive beings and our individual perception of normal is fluid. Children often see shadows and believe there are monsters in their closet so they are afraid of opening the door but through experience learn this is normal and a part of life. Though it may be a simple example, this is how we compile schemas over time.
Coping mechanisms change with time and with illnesses, this is often the case: you learn that this is the present and the past is no longer where you are in the time spectrum. When the situation is new and unfamiliar it sometimes over reaches our already “programmed” mechanisms and we are forced to develop a new schema (Hack, 237). I personally experienced this at the beginning of the fall semester I was diagnosed with Lyme disease, a condition that causes joint pain, fatigue, and severe headaches and is often accompanied by cognitive impairment. Symptoms are hard to manage not only because of the variety but also because intensity varies from day to day and recovery is not linear. The research is limited and often inconclusive, leaving most physicians unqualified to treat the disease. Therefore, many patients, like myself, heavily rely on the advice and expertise of a specialist. Pelligrino’s point that “The state of being ill is therefore a state of ‘wounded humanity’, of a person compromised in his fundamental capacity to deal with his vulnerability” is spot on (Ackerman, 15). Not only are long-term goals affected but the way in which one goes about their daily routine can be abruptly altered. I went from being able to practice for 2 hours a day to being unable to physically lift myself out of bed.
Experiencing intense physical pain with little relief is uncomfortable but the cognitive constraint is much worse. I was so overwhelmed with the new day-to-day me that I lost the ability to confidently make choices. It could take me an hour to make a simple decision of what cereal to eat for breakfast and even after I finished the bowl I was still unsure if I made the “right” decision. The immense pressure that new patients feel to make only “right” decisions is mentally and emotionally taxing and can compromise the patient’s own autonomy (Schofield, 2). The argument can be made that considering the situation, although competent, I was not in any condition to give informed medical consent and neither was my family. It’s necessary to acknowledge the slippery slope of violating patient autonomy when the physician takes on the responsibility of decision maker but before the patient has adjusted to their new normal it may be necessary for their long-term well being.
Ackerman, T. F. (1982). Why Doctors Should Intervene. The Hastings Center Report, 12(4), 14. doi:10.2307
Hack, T.F., and Degner, L.F. (2003). “Coping responses following breast cancer diagnosis predict psychological adjustment three years later.” Psycho-Oncology, 13(4): 235-247.
Schofield, P. E., Butow, P. N., Thompson, J. F., Tattersall, M. H., Beeney, L. J., & Dunn, S. M. (2003, January 01). Psychological responses of patients receiving a diagnosis of cancer. https://academic.oup.com/annonc/article/14/1/48/130229/Psychological-responses-of-patients-receiving-a
I really like the point you have made in this post about how physician intervention near the outset of a medical condition may not only be justified, but necessary for the patient’s well-being. New medical conditions can certainly be overwhelming and place undue stress barriers in front of autonomous decision-making. While, if I was in that situation, I would also want to adhere very closely to my physician’s instructions, I think it is a bit too paternalistic to argue that the physician should be the unilateral decision-maker. In this type of a case, I would argue that there still needs to be some element of choice, just as with small children there is the unilateral decision that socks will be worn but the children get to pick the color of the socks. I believe that there are two major categories of applicable decisions here. The first is the patient’s retained ability to withdraw his or her consent to a course of treatment. The only circumstance where it is acceptable to take away this ability is in a case of incompetence, and even then I still have some issues with it. Secondly, I believe that the physicians have a duty to implement some degree of autonomy in their courses of intervention when at all possible. Whether this takes the form of seemingly inconsequential decision like the flavor of a mouthwash being used, or perhaps a more stressful decision like whether a patient would like the drug in the form of an injection or a pill, implementing autonomy into the process would make the physician’s intervention (which I agree with you in that it is highly important in some situations) much more dignified and geared towards the needs and desires of the patient.
I also find it difficult to balance autonomy with nonmaleficence with autonomy, especially when a patient is mentally competent most of the time, but might be suffering from pain or mental confusion or fatigue when they have to make some of the most important decisions. I also really appreciate the personal perspective on the topic. I think that this is, as you acknowledge, a very slippery slope. It’s imperative that doctors, inrsurance companies, or hospital administrators don’t see physicians or statistical analysis of diseases as the end-all-be-all of treatment. It’s also very difficult to constantly evaluate patient competency, especially if mental state or emotions are self-reported. I think that doctors ought to be granted some extra abilities to make the best decisions they can on behalf of patients while the patients attempt to cope with their disease if it is significant. Even with this power, it is imperative that the doctors are sensitive to the fragile emotional and physical states of their patients.