Autonomy: But Whose Autonomy?
Autonomy is an ethical principle the definition of which includes the person’s ability to make personal and independent choices. In medical practice, it is the right of a patient to make their own medical decisions based, in part, on information provided by the patient’s physician. It is the responsibility of the physician to provide the patient with all the risks, benefits and alternatives regarding the medical issue. If at the time of a needed decision, the patient is unconscious or doesn’t demonstrate the capacity to make such decisions, then what they have expressed in the past by writing or communication with others or through the assignment of surrogates may be sufficient to establish a decision. Sometimes, in medicine, there is a question of whether the patient actually has the capacity to make a medical decision even when the patient is conscious. It is the responsibility of the attending physician to finally answer that question. If there are no prior writings, communications or surrogates available as there often may be with a patient brought into the emergency room of a hospital, it becomes the additional responsibility of the physician to not only decide on the patient’s mental capacity but if decided as incapacitated to make the medical decision for the patient. The physician’s decision must be made only in the patient’s best interest.
A case that is currently in the news and which will be going to trial shortly is that of a patient who while being attended in a hospital emergency room for an injury strongly refused a rectal exam but was evaluated by the doctor as not having the capacity to make his own decision and since there were no surrogates available to speak for the patient, the patient was allegedly then held down and later sedated despite the patient’s continued protestations. The story is documented in a New York Times Blog article along with a great number of readers’ commentaries. All the facts are not known to the public and hopefully will come out in the upcoming trial of a lawsuit by the patient.
Of interest to our blog is how patient autonomy, to make one’s own decision, is affected by the situation, an alleged emergency medical evaluation for a potential harmful injury in which a patient refuses what the physician believes is an essential examination. In this situation, does the physician’s autonomous professional decision (in the past called “paternalism”) regarding the patient’s mental capacity to make decisions trump the patient’s own right to autonomy? Or another way of putting it, should all patients who enter an emergency room know that it is possible that the doctor will decide that the patient is unable to make an informed consent decision for a procedure and that the doctor will perform the procedure even with the expressed refusal of the patient? ..Maurice.
Graphic: Painting "Judith Beheading Holofernes" by Artemisia Gentileschi ca 1620