In Pence (2010), autonomy meant that individuals should be left alone to make their own medical decisions as long as the extent of those decisions are possible and do not harm others. John Stuart Mill argued in his harm principle that “the only purpose for which power can rightfully be exercised over any member of a civilized community, against his will, is to prevent harm to others,” otherwise in matters concerming that individual’s body and mind: “the individual is sovereign,” (Pence 2010).Since the 1960s, autonomy meant that a patient had the right to make decisions for their body, including that of death and reproduction (Pence 2010). No one can force medical procedures on a patient, or deny them because of their own agenda or possible gain. During its first two decades, bioethics (1962-1982) considered autonomy as the most important of principles, because it gave competent adults the ability to make controversial decisions about the right to end one’s life, reproduction, and declining involvement in experiments (Pence 2010).
In Pantilat 2008, individuals who are autonomous act with intention, and understanding, and without controlling influences. Beyond that, autonomy requires physicians to create the conditions necessary for autonomous choice in their patients by providing them with guidance, background, and information so that they are able to make the best informed decision, (Pantilat 2008). It is the job of a physician to make sure that a patient is adequately informed about their situation, and that they address any fears or misconceptions that the patient may have, while also providing counsel when a patient seems to make decisions that may be disruptive to their health or well being, (Pantilat 2008). Autonomy obligates physicians to maintain confidentiality, seek informed consent for medical procedures and treatments, disclose information about a patient’s disease, and uphold a patient’s privacy (Pantilat 2008).
Principlism and autonomy were formally established in the Belmont Report in 1979 to provide a “succinct description of the mandate for review of research involving human research participants,” (Basic Principles). The Belmont Report was the result of the Nuremberg Code dealing with Nazi biomedical researchers during World War I1, and a variety of US ethical violations including the Thalidomide case, and the Tuskegee Syphilis Study, (Bulger 2007).
From 1962 to 1982, bioethics considered autonomy to be the most important of the four principles of Principlism including autonomy, beneficence, nonmaleficence, and justice, but since then bioethics has acknowledged that other factors such as the good of the family, and a physician’s character must also be considered (Pence 2010). Autonomy faces conflict in situations concerning suicide, and competence scenarios like vaccination, when in these cases, an individual ‘s decisions may not be for the best of that individual, affecting their family, and their community, or conflicting with another principle like beneficence. Principlism does not pose a method to deal with two or more conflicting principles. Decisions a patient makes for themselves medically involve other factors like family, and a physician’s moral character. These limitations will be discussed with a hypothetical scenario attached to help explore the dilemmas autonomy may face or cause below.
Suicide. In the case of suicide, autonomy may conflict with the beneficence principle. Beneficence is an act done for the benefit or the good of another (Pantilat 2008). Beneficence requires physicians to “First, do no harm,” which is not the case in the matter of physician- assisted suicide, or attempted suicide. A nurse may encounter a conflict with the employment of the autonomy principle when a person attempts suicide because it conflicts with a medical professions “First, do no harm” principle. In a physician-patient relationship, a physician or medical professional has the obligation to “prevent and remove harms, and weigh possible benefits against possible risks of an action” (Pantilat 2008). In the case of attempted suicide, physicians must do all possible to resuscitate the patient, because it is the first priority of a physician to ensure the patient’s medical safety, and only once this is done, can the physician assess the circumstances of an attempt (Carrigan & Lynch, 2003).
Paternalism is defined as the “interfering with a person’s freedom for his or her own good,” (Andre & Velasquez, 1991). Designed with the best interest in mind, paternalism has many underlining effects in medicine, underlining laws, actions, and practices against euthanasia, and drug abuse among other things (Andre & Velasquez, 1991). Leading to a conflict in the value placed in individual freedom (autonomy) and the value of placed on protecting the well being of others (beneficence and paternalism), (Andre, 1991). Also is the issue of whether a patient was competent when attempted suicide, when asking the 26 people questioned after they survived jumping from the Golden Gate Bridge in San Francisco, all 26 patients “regretted their actions and wanted to live,” (Firestone). A solution to this problem may present itself in the do-not-resuscitate order (DNR order), which allows a patient to decide whether they want to receive CPR if they stop breathing, or if their heart stops, allowing physicians to write the order after consult their patients, or their proxy, and thus gaining informed consent (Gersten 2014).
Competence. A nurse may encounter a conflict with autonomy when dealing with the involuntary psychiatric treatment homeless schizophrenic, and children who are given the choice of whether they may receive a vaccine. In the case of a homeless schizophrenic who is involuntarily committed to a psychiatric hospital (Pence 2010), or in a child’s right to refuse vaccinations, autonomy is again conflicted with beneficence.
Autonomy dictates that an individual’s right to make decisions for themselves and their bodies be respected, and allowed, but when it conflicts with another principle in the same ethical theory, which takes precedence? In the case of attempted suicide, physicians and medical professionals must do whatever is necessary to revive their patient, and only after that patient has been revived can the physician assess the circumstances of the case, and the capacity of the patient. The physician may advise that patient, and then consult with that patient if they do decide they would like request a DNR orde, and only after that order is established must autonomy be respected as this allows physicians to be rid of liability.
In the case of the children against vaccinations, and the homeless schizophrenic, it can be argued that children “lack the emotional and cognitive capacity to always know what is in their best interest” (Andre, 1991), and thus it is justified to limited their autonomy as their lack of vaccination could result in harm to the health and well-being of others, and that a schizophrenic lacks the cognitive and mental capacity to make rational, informed decisions for their wellbeing. Children do not have the mental ability to make decisions about what vaccinations they receive as it is up to the parent to make decisions for the child’s wel-being, and only after a schizophrenic has been deemed competent by a medical professional or their proxy, may they be able to make decisions for themselves. Autonomy may not be completely violated by either of these scenarios either because autonomy involves complete understanding, and informed decisions which a schizophrenic or a child may not be able to make.
References
- Andre, C., & Velasquez, M. (1991). Paternalism and Freedom of Choice. Retrieved from http://www.scu.edu/ethics/publications/iie/v4n2/owngood.html Bulger, J. W. (n.d.). Principlism. P RINCIPLISM. Retrieved from http://www.uvu.edu/ethics/seac/Bulger-Principlism.pdf
- Carrigan, C. G., & Lynch, D. J. (n.d.). Managing Suicide Attempts: Guidelines for the Primary Care Physician. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/
- Firestone, T. (n.d.). Suicide: What Therapists Need to Known. SUICIDE: WHAT THERAPISTS NEED TO KNOW. Retrieved from http://www.apa.org/education/ce/suicide.pdf Gersten, T. (n.d.). Do-not-resuscitate order: MedlinePlus Medical Encyclopedia. Retrieved from http://www.nlm.nihgov/medlineplus/ency/patientinstructions/000473.htm
- Pantilat, S. (2008). Autonomy vs. Beneficence. Retrieved February 01, 2015, from http://missinglink.ucsf.edu/Im/ethics/Content620Pages/fast_fact_auton_bene. htm Pence, G. E., & Pence, G. E. (2010). Chapter 9: Research on Human Subject. In Medical ethics: Accounts of ground-breaking cases (pp. 177-197). New York: McGraw-Hil. Sargent, J. (Director). (1997). Miss Evers’ Boys [Motion picture on DVD]. HBO.
- Woodward, B. (n.d.). Basic Principles of the Belmont Report. Basic Principles of the Belmont Report. Retrieved February 01, 2015, from http://www.drexelmed.edu/drexel- pdi/research-clinical/belmont_ report.pdf Woodward, B. (n.d.). Basic Principles of the Belmont Report. Retrieved January 31, 2015, from http://www.drexelmed.edu/drexel-pdf/research-clinical/belmont report.pdf
