Ethical and Legal Implications of Autonomy

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Within the healthcare system, it is important for healthcare professionals to maintain ethical standards, including those that govern respect for persons, a primary component of which is autonomy, and beneficence.

According to R.G. Rodriguez, Ph.D. (2009), autonomy is an element within the professional code of healthcare ethics that allows for a patient to govern themselves in the event that they are rational, competent, conscious and not coerced. This definition is significant because it provides indications both for the patient’s autonomy as well as situations where the requirements for autonomy have not been met and autonomy should therefore not be fully granted. Spicer (2005) qualifies autonomy by adding that patients must be informed in order to make an appropriate decision; must have the capacity to decide; and must be free from coercion. These definitions differ slightly in the emphasis of information required to be autonomous; however, capacity as defined by Spicer (2005) encompasses rationality, competency and consciousness. In effect, both definitions are mutually supportive and establish complementary guidelines in determining autonomy.

The definition offered by Fremgen (2009) is limited as it describes autonomy as “independence for their beliefs” (pg. 176). The definition provided fails because it addresses only religious considerations, as well as a person’s right to decision-making based solely on competence: “As long as a person is competent, he or she has the right to make his or her own decision” (pg. 176). This does not address matters of relevance involved with determining autonomy, including consciousness or freedom from coercion. “Bioethical and legal issues arise when a person is called upon to make this decision, based upon his or her own religious beliefs, for another person such as a child or an elderly or incompetent adult” (Fremgen, 2009, pg. 176). The assumption that religious considerations are the main contributing factor for dilemmas of autonomy is myopic and impractical as many social, cultural, familial, personal and financial components may contribute to a person’s decision making with regards to healthcare treatments and options. The aforementioned definition given by Fremgen also implies that people without religious considerations would not have ethical dilemmas when making healthcare decisions for themselves or others. However, one would conclude that the complexity of the human condition is still relevant even in the absence of religious belief. Therefore, in consideration of the inefficiency and of the definition provided by Fremgen, the definitions given by Rodriguez and Spicer will be used to analyze the following dilemmas.

Within the ethical guidelines of the healthcare profession, therapeutic privilege offers an option for nondisclosure under certain guidelines. “Physicians may withhold information about a patient’s diagnosis or treatment when disclosing it would pose a serious psychological threat, so serious a threat as to be medically contraindicated” (Wynia, 2004, p. 14). Following the guideline of therapeutic privilege, the provider may not disclose information simply because the information would cause the patient to choose a different course of action, but only in the event that the information would cause significant unnecessary harm if disclosed and is therefore determined to be medically contraindicated (Wynia, 2004). In this way, providers partially disregard the first ethical principle, selectively disclosing information and therefore not being fully truthful and allowing for the necessary information for complete autonomy, in lieu of the second and third principles, beneficence and non-malfeasance. However, beneficence is not sufficient; the judgment must be subjective to preventing actual harm.

The second principle within healthcare ethics is beneficence (Fremgen, 2009; Rodriguez, 2009; Gauthier, 2005). Beneficence means to “act with charity and kindness” (Rodriguez, 2009); it means to use one’s skills and professional authority to care for, comfort, and if possible, cure a patient. Beneficence implies that one will fairly and justly provide services with the intention of another’s improving the patient’s wellbeing. Rodriguez’s definition is valid because it indicates the primary values of beneficence.

When deciding ethical dilemmas, it is important to not only consider the ethical obligations; respecting a person and acting with beneficence, but it is also necessary to consider the legal implications of actions within the context of the healthcare setting. The following scenarios are presented with both ethical and legal considerations:

In the intensive care unit, you are working on a patient in a very unstable state. The woman and her children (who were all killed) had been in an accident. It is clear that further emotional trauma would be disastrous to the patient and may cause her death. In a lucid moment, she looks at you and asks, “How are my children?” Is this an instance when therapeutic privilege seems reasonable? Whether you decide yes or no to the therapeutic privilege question, write a sentence that you think would be the most appropriate answer for the patient.

The primary principle of healthcare ethics being respect for persons, it is important to reflect on the components of respect, mainly: autonomy, truthfulness, confidentiality and fidelity (Rodriguez, 2009). It is necessary to carefully consider the provider’s responsibility to the patient as well as the ethical duty expected by the profession. Beyond justice, the provider has a duty to respect the person, therefore allowing for autonomy as well as being truthful; beneficence, acting in a way that lends comfort, care and possible cure to the patient; and non-malfeasance, meaning that there is no harm caused.

The above mentioned scenario offers an ethical dilemma that may appear to be conflicting. It is the provider’s duty to be truthful, but also to cause no harm. In the event that the provider is truthful, harm, even death, is possible.

If the provider tells the patient that her children are dead, given the current situation, the patient may die due to the additional emotional trauma. In this manner, by telling the patient that the children have died, the provider would be causing harm; risking the patient’s death due to this additional emotional trauma would be medically contraindicated.

However, if the provider does not inform the patient of the news, then the provider is not being fully truthful and respectful of the patient. Under absolutely no circumstances should the provider lie to the patient; saying that the children are fine or any other statement simply to offer comfort. Such a lie would constitute a breach of ethical standards as it is not truthful and may cause greater long-term damage when the woman learns of their death. Lying to the patient is inadvisable and may lead to civil litigation since it would be outside of the professional ethical norms.

Under the guidelines of therapeutic privilege, a provider may not disclose information if such knowledge is dangerous, causing such significant emotional trauma as to be medically contraindicated. In this scenario, one may consider the immediate disclosure to be a matter of therapeutic privilege because the emotional trauma resulting from the information would cause significant emotional trauma possibly resulting in death. Given the likelihood of significant danger at the current time, the provider should not answer the question, but also not offer any false hope or lies. Additionally, autonomy is contingent on rationality; in the patient’s current condition of shock and significant physical trauma, she does not qualify for complete autonomy.

One appropriate response may be to redirect the patient’s focus to her own injuries and treatment, for example: “Ms. Doe, we are doing everything possible to help you right now. We need to ask you some questions about your medical history.” As the patient is not consistently lucid, this redirection would offer additional time to stabilize her condition before adding the additional emotional burden of her children’s death.

You are working late and you enter the patient’s room to find that she has climbed out on the window ledge. She appears to be crying and tells you to leave her alone.

In the abovementioned scenario, the woman on the ledge offers another ethical consideration, contrasting the autonomy of the patient’s wishes to be left alone against the provider’s responsibility for offering care. The patient exhibits clear signs of lacking the necessary components of autonomy. Her actions are clearly not rational and arguably not competent as they are likely indications of mental illness, risk of self harm or even suicide. In this matter, the clear decision is to not fulfill her wishes to be left alone. However, staying in the room or climbing out on the ledge is not a sufficient answer to this situation. This situation needs immediate response: security and police/EMS services need to be notified. Any and all possible means to prevent harm need to be taken.

Beyond the ethical considerations, it is necessary to consider the legal impact of inaction. Had the provider observed the patient’s wishes, he or she would have been liable for any harm that came to the patient (Jenner & Welch, 2001). When a patient is under professional care, it is important for the provider to protect them from harm, even if the harm is caused by themselves as in the case of psychiatric disorders. If the provider fails to reasonably safeguard against actions of self-harm or suicide, he or she will likely be civilly liable for malpractice and negligence (Jenner & Welch, 2001).

Your elderly patient hates to have the bed rails up and tells you to leave them down.

Ethically, this scenario does not offer enough information to conclude if there is a legitimate dilemma: whether or not the patient is autonomous is unclear. The indication of age does not necessarily indicate any potential harm. There is no mention as to whether there are physician orders regarding the matter of the bed rails. The setting of the situation is unclear. More information needs to be obtained before any actual ethical determinations may be made.

However, while this scenario could offer an ethical dilemma given additional information, the more significant consideration is that of the legality of the action. Bed rails qualify as restraints; restraints must be used under the order and direction of a physician (Greenwich Hospital, 2005). Restraints are used only when absolutely necessary; to use them in any other fashion or without proper indications or medical direction could constitute unlawful confinement and may open the provider and healthcare site up to civil or criminal ramifications.

Considering all aspects of a dilemma is important, however it is necessary to consider not only the ethical factors but also the legal responsibilities within the healthcare setting.

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