Ethics toolkit for medical students

Autonomy or self-determination as a medical student

Location: England Wales Northern Ireland
Audience: Medical students
Updated: Friday 1 May 2020

A respect for patient autonomy is probably the single most talked-about principle or concept in medical ethics. A respect for competent decisions by adult patients is also a cornerstone of medical law.

Given the practical, legal and ethical significance of respecting autonomy, we outline some of its more important features here.

 

What do we mean by autonomy?

In medical practice, autonomy is usually expressed as the right of competent adults to make informed decisions about their own medical care. The principle underlies the requirement to seek the consent or informed agreement of the patient before any investigation or treatment takes place. The principle is perhaps seen at its most forcible when patients exercise their autonomy by refusing life-sustaining treatment.

 

What the law says

An adult patient who… suffers from no mental incapacity has an absolute right to choose whether to consent to medical treatment… This right of choice is not limited to decisions which others might regard as sensible. It exists notwithstanding that the reasons for making the choice are rational, irrational, unknown or even non-existent.

Lord Donaldson. Re T (Adult) [1992] 4 All ER 649.

 

The conditions for autonomy

Two conditions are ordinarily required before a decision can be regarded as autonomous. The individual has to have the relevant internal capacities for self-government and has to be free from external constraints. In a medical context, a decision is ordinarily regarded as autonomous where the individual has the capacity to make the relevant decision, has sufficient information to make the decision and does so voluntarily.

As we can see from Lord Donaldson’s statement in Re:T, providing the adult has the relevant capacity a decision does not have to be sensible or, in any objective sense, in the individual’s interests.

 

Decisions where autonomy is lacking

Given that there is a strong obligation to respect the decisions of autonomous adults – in relation to medical treatment, the only possible exception is the provision of compulsory treatment under mental health legislation – how should we proceed when the conditions for autonomous decision-making are not met?

Much will depend on the reasons why the conditions are lacking. If someone is being coerced into making a decision then it cannot be said to be theirs and should not be respected. In reality, coercion is not always easy to detect. A young woman who visits a GP with her partner for a termination of pregnancy may, for example, be under pressure to proceed. If a doctor had concerns about coercion, good practice would involve spending some time alone with the patient in order to confirm that the decision is genuinely hers.

 

Food for thought

The only part of the conduct of any one, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.

John Stuart Mill on liberty

Where patients lack the capacity to make a decision, it follows necessarily that decisions must be made on their behalf. Very young children ordinarily have the majority of decisions made by parents and carers.

Where adults lack capacity, health care decisions are ordinarily made by the health professional in overall charge of their care, although adults can appoint someone to make decisions on their behalf.

In practice, decisions relating to incapacitated adults are closely regulated by law and further information is given later in the toolkit.

 

What’s the moral problem?

Should someone suffering from severe anorexia be forcibly fed? We have seen that a competent adult can refuse medical treatment even if it will result in their death. Why then should an adult of ordinary intelligence not have a decision to refuse food respected?

The justification is, usually, that the anorexia has undermined the ability to make an autonomous decision. The decision to refuse food, it is said, is not authentically theirs, rather it springs from the mental disorder that has the adult in its grip. Force feeding could be described as a paternalistic intervention designed to facilitate further treatment, with the intention of resurrecting the ability to make authentically autonomous decisions.

 

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