Ep_2 health

Hello, I’m Dr. Sarah Hall, your guide to the wonderful world of health ethics. Welcome to episode 2: Autonomy

Travel back in time with me to the 5th century BC. Hippocrates was an ancient Greek physician who developed the Hippocratic Oath – the oldest health ethics document in history. Physicians swore to uphold particular ethical standards like helping the sick, abstaining from intentional wrong-doing – whether the patient is male or female, bond or free - and keeping medical issues confidential.

In today’s society, we have four core principles of healthcare ethics: autonomy, beneficence, nonmaleficence, and justice. Autonomy means self-governance, beneficence means doing good, nonmaleficence means doing no harm, and justice means treating people fairly.

Today we’ll focus on autonomy. The word “autonomy” is of Greek origin. “Aut” means “self” and “nomos” means “law”. Autonomy refers to the right to govern yourself, like making your own life choices and plans.

In the context of healthcare, this means people are free to choose which treatments to pursue or not pursue, granted they have all the information they need. According to the Prudent Person rule, this information includes the diagnosis, nature and purpose of proposed treatment, known risks and consequences of proposed treatment, expected benefits from treatment and assessment of likelihood these benefits are to occur, all alternative treatments that are reasonable, prognosis if no treatment is given, and other factors such as pain, impact on lifestyle and work, economic costs, and whether or not treatment is covered by insurance. The patient can then consider their financial situation, quality of life, strain on relationships, religious beliefs and other factors to make their autonomous decision. The patient or a lawful surrogate must give informed consent before being treated. Autonomy says that unless there are special exceptions, patients’ treatment decisions are up to them – not the doctor, nurse, or other healthcare professional.

What are some of these special exceptions? Remember the three C’s: capacity, competency, and coercion. Capacity means the patient understands the illness, treatment options, and consequences of their decision. Competency refers to specific abilities, like making a rational decision about treatment. Coercion references undue influence or force that may invalidate consent.

Remember that all patients over 18 years of age are assumed to have competency and capacity unless it is clear there is something affecting the patient’s judgement when it comes to understanding their diagnosis or weighing their treatment options.

Circumstances in which patients might not have capacity or competency to make an informed choice include age, language barriers, psychiatric illness like schizophrenia and bipolar disorder, neurodegenerative diseases like Alzheimer’s and Parkinson’s disease, mental impairment, or brain damage. If the patient is comatose, they are obviously unable to understand the diagnosis and treatment options and cannot give consent. Competency is not a yes-no category. It is a continuum. It can be tricky to determine if someone is competent to make a medical decision for themselves.

Coercion includes things like family pressure – for example a teenager who is being threatened by her family that she can no longer live with them unless she chooses to abort when she becomes pregnant. The use of drugs, whether illegal or pain management at the hospital could in some cases be considered equivalent to force. Health professionals threatening to withhold future treatment may also invalidate consent.

One example of flagrant coercion was in the 1970s when over 3,400 Native American women were sterilized. Some were sterilized without their knowledge or consent. Many were threatened that if they would not be sterilized, they would be denied welfare benefits. The federally-funded Indian Health Service repeatedly refused to deliver Native American babies until their mothers, in labor, consented to sterilization. Many unknowingly gave consent since instructions were not given in their native language. The physicians were paid more for performing hysterectomies than for prescribing other forms of birth control and these sterilization procedures were seen as practice and training for physicians and medical residents. This was a violation of autonomy, even when consent was given, due to the coercive nature of obtaining consent.

To determine whether someone has competency, capacity, and whether or not they were coerced, ask yourself the question: Do any of these influences substantially diminish the person’s freedom so that there is inadequate capacity for a valid consent?

Now let’s talk about another category of exception to informed consent: emergency exceptions. I will illustrate with an example. A 20-year-old woman was hit by a car while she was riding her bike across the street. She was rushed to the hospital. She is unconscious and her parents can’t be reached. She needs immediate surgery or she could die. You don’t have consent. Do you perform the surgery?

As important as informed consent is, if the doctors were to wait for the green light, the woman could die in the meantime. As this example illustrates, there are three conditions that must be present in order to treat without consent in the case of emergencies.

1.	The patient must be incapable of giving consent (and the wishes of the patient are not known) and no lawful surrogate is available to give consent
2.	There is danger to life or danger of a serious impairment of health
3.	Immediate treatment is necessary to avert these dangers

Autonomy is extremely important in present day health ethics in our society. However, some argue there are there are possible rationalizations for violating the principle of autonomy. The first is to stop an individual from causing harm to others. For example, quarantining someone against their will if they have a deadly and highly contagious disease. The second rationalization is legislating morality to prevent harm, like requiring all nurses to get an annual flu vaccine. The third rationalization is violating autonomy for the sake of society, such as compulsory school vaccination laws. The last is the paternalist principle, which basically says “daddy knows best” except in this case daddy is the healthcare professional or government. It is compelling someone to do something in order to benefit that person or prevent that person from harming themselves. Some examples of this are seatbelt and helmet laws, soda size bans, and trans fat bans.

Paternalism is an important term to know. Weak Paternalism is the absence of consent or overriding consent of doubtfully competent person. Strong Paternalism is overriding the wishes of a competent person.

One example of weak paternalism is temporarily using restraints in a hospital setting on a disoriented person to stop them from hurting themselves. Examples of strong paternalism include giving a blood transfusion to someone who has refused on religious grounds, and resuscitating someone who has earlier stated they do not want to be resuscitated.

In our society, weak paternalism can only be used in a limited number of cases. Strong paternalism is NOT allowed except possibly in the case of therapeutic privilege, and even then it should be a unique situation.

Therapeutic privilege is when a healthcare professional purposely withholds information on the grounds that giving the information is likely to seriously and immediately harm the patient. For example, the patient is severely depressed and giving the information could prompt suicide. Therapeutic privilege should never be used to try to get the patient to accept treatment they would not want if given all the information. When using therapeutic privilege, it should be temporary and there should be a plan to give the information when patients are prepared to handle it. There must be very good reasons for using therapeutic privilege since withholding information is generally considered unethical. The burden of proof to justify using therapeutic privilege is on the medical provide. Therapeutic privilege is often NOT held up in court since it is considered a breach of patient autonomy, so be very careful with this.

In summary, autonomy and informed consent are extremely important in healthcare. In order to give informed consent, all relevant information must be given in order for patients to weigh risks and benefits of treatment. All patients over 18 are generally able to make their own medical decisions, with possible exceptions being issues of capacity, competency, or coercion. Informed consent may not be necessary in emergency exceptions that fit a specific set of criteria. Weak paternalism can be used in a limited number of cases, but strong paternalism is not considered to be ethical, with the possible very rare exception of therapeutic privilege.

I hope you’re enjoyed learning more about autonomy and informed consent. Stay tuned to learn more about beneficence, nonmaleficence, justice, and confidentiality. See you next time!