The concept of complexity of respect for personal autonomy is quite complicated. Autonomy in medical ethics is defined as, “the ability of the person to make his or her own decisions” (Autonomy-Wikipedia). Several questions such as which request to abide by, and how to know if a patient wants full or partial disclosure are entirely debatable. In more instances than not patients change their minds regarding treatments, and this brings about the question of which request do we follow? Childress questions, “Which choices and actions should we respect? In particular is it justifiable to override a patient’s present autonomous choices and actions in the light of his/her past or (anticipated) future choices and actions?” (Childress, 310) This is the key question I am going to address in my argument.
When it comes to present versus past or future autonomy, Childress believes that the present autonomous statement is the one to listen to. I both agree and disagree with parts of this statement. Firstly, if one is in an autonomous state of mind and is able to make his or her own decisions, then their present statements should be considered. However, if one’s present autonomous requests completely contradict previous requests I think past autonomous opinions should be weighted more heavily. As well exampled in Childress’s argument , a woman who has been courageous about her treatment all her life who suddenly decides she wants to stop treatment is acting out of character. Although this is her present autonomous request, it should not be the end- all- be- all decision, because the authenticity is questionable.
Authenticity is another important concept regarding contradictory choices and is defined as, “an action is consistent with the attitudes, values, dispositions and life plans of the person” (Childress, 311). As the previous example portrayed, the woman’s authenticity was not intact, because her new rash opinion entirely contradicted what she had previously believed. Childress also argues that, “it would be a mistake to make authenticity a criterion of autonomy. At most, actions apparently out of character and inauthentic can be caution flags that warn others to request explanations and justifications to determine whether the actions are autonomous” (Childress, 311). This, I disagree with, because authenticity should be considered when a new judgment is inconsistent with previous ones. If a new opinion harshly contradicts years worth of beliefs then wouldn’t it make sense to more heavily consider prior opinions? Although this is very contradictory, an inauthentic statement should not change everything, it should mean little because long-standing opinions and beliefs more accurately represent one’s true stance. Another important point brought about by Levi in Respecting Patient Autonomy is that, “..in many cases present autonomous decisions conflict with the interest of preserving or promoting future autonomy, and one must choose between the two. This situation is perhaps most pressing when autonomous are greatly imprudent and likely to compromise future well-being in addition to autonomy” (Levi, 83). This statement entirely supports my argument because usually the inauthentic, imprudent judgments of patients that are inconsistent with their character greatly compromises their future well-being. Overall, I believe that past autonomous decisions that represent years worth of beliefs and opinions should be considered more heavily than rash, present autonomous decisions.
Interesting link regarding Doctors not respecting autonomy and pushing their own beliefs:
Sources:
1.)http://en.wikipedia.org/wiki/Autonomy
2.) Arguing About Bioethics- Holland
3.) Respecting Patient Autonomy- Levi
4.) Pressing Patients to Change Their Minds- Lerner
Your stance on authenticity is certainly commendable. I do also think that in the majority of cases it is important to look at a person’s usual attitude in a situation. But what if someone, in a manner that could be considered out of character, genuinely wants to give up on a treatment? While this decision would have implications for a patient’s family, I think a doctor should respect a patient’s change of heart if the patient is truly in a stable state of mind. A doctor is obligated as a care giver to act in the best interest of the patient.
While Childress defines “authenticity” as an important concept, I think it’s the most controversial component of autonomous decision-making. Who says that a patient can change his “attitudes, values, dispositions and life plans” overnight, and it wouldn’t be an authentic decision? Maybe they had a change of heart and have decided against treatment. This goes against the patient’s previous values and life plans, but it could be a completely authentic, autonomous decision. I disagree with your view that long-standing beliefs should factor into the decision more than a more recent change in values. I think the best idea in this situation is to sit down and have a talk with the patient to reason through the decision and make sure the patient can provide substantial reasoning for his decision.
The article you included brings an interesting concept into the picture- “beneficent persuasion,” “using knowledge of decisional psychology to influence the patient to choose that approach” (Swindell article). Basically, the doctor felt that NOT persuading his patient to undergo surgery would do more harm than good, which violates the Hippocratic oath. In my opinion, the doctor crossed the line here. Imagine if the story ended differently- the patient could have died in surgery and it would have been because the doctor strongly persuaded the patient into having this surgery. Also, the doctor might have many patients similar to the patient in the article- is he supposed to have such a strong outreach to all of his other patients, too? This is why we have doctor-patient boundaries and respect for autonomous decisions.
http://www.annfammed.org/content/8/3/260.short
Logically, I think the concept of authenticity makes sense. It would be out of character for a patient to make a decision that is not consistent with his or her attitudes, values, or life plans. If it is a case where the patient first makes a decision in which his authenticity is intact but then changes his mind, I don’t think his second decision is any less important than his first decision. It’s possible that the person’s decision was genuine after taking other things into consideration. Maybe he changed his mind after speaking to his family. While others may argue that doesn’t make the decision autonomous, I disagree. A person has the autonomy to choose whether he wants to listen to the other’s advice. There are people who choose to listen to their family and their are people who choose not to. Whatever the case is, we shouldn’t think that present autonomous decisions aren’t worth considering because we might be making wrongful assumptions.
I think your argument brings into question the idea of whether or not we should have to justify or explain autonomous decisions. If long-standing beliefs are a better indication of the person’s true stance, what do we do about someone who has been denying treatment for a long time but then decides to go through with it? Whether or not they have a personal change of heart, are coerced by a loved one or convinced by the doctor, does it matter? Is the doctor going to question whether or not he should comply with the patient’s newly developed wishes to be cured through the treatment that the doctor himself had been recommending? Therefore, I think that the doctor must be aware of what is going on with the patient, and why they might be making a certain decision. It comes back to the fact that doctors cannot treat people like machines needing to be repaired. Each person is different, and has his own unique situation that contributes to their decisions.
This matter is something that must be dealt with on a case-to-case basis. Although we should not be required to explain or justify a personal decision, it is important for the doctor to try and understand their patient’s situation and what they might be feeling as a unique individual. However, the only way this can happen is if the patient is willing to trust the doctor and honestly disclose things that may help the doctor’s understanding.
we would like to thank you for this wonderful post. As a person dealing with commercial real estate loan data I find it very interesting.