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PubMed2006

Autonomy (vs. sociotropy) and depressive symptoms in quitting smoking: evidence for trait-congruence and the role of gender.

According to Beck's cognitive theory of depression, autonomy (high achievement concerns) and sociotropy (high interpersonal concerns) are vulnerability factors for depression when achievement or interpersonal stressors, respectively, are experienced. This hypothesis was tested among men and women attempting to quit smoking, an achievement stressor that can provoke depressive symptoms. Smokers recruited from the community (N=210) provided information about their quit attempt through mailed questionnaires. For the 48-h period following the quit, relationships among autonomy, sociotropy, coping, depressive symptoms and lapsing were assessed. Structural equation models supported the trait-congruence hypothesis because greater autonomy, but not sociotropy, was associated with elevated depressive symptoms among both men and women smokers. However, results were stronger for men (beta=.47, p=.0001) than for women (beta=.20, p=.05). After accounting for autonomy's relationship with depressive symptoms, greater autonomy was inversely associated with lapsing among men (beta=-.35, p=.01), but not women. Results point to the potential usefulness of a theoretical approach to understanding relationships between depressive symptoms and smoking cessation, and indicate that autonomous personality may be an important factor in smoking cessation in men.

Adaptation, Psychological↗
PubMed1991

Another view of autonomy: arranging for consent in advance.

A review of the issues surrounding a Ulysses contract--a prior consent agreement--juxtaposes the autonomy expressed by a stabilized patient who gives consent in advance for treatment during an acute break and the exercise of a patient's right to refuse as protected by legal advocates. Ideally, the first approach would enable persons to claim control over their lives and promote a collaborative process involving patient, family members, and professionals. But feedback from an informal canvassing of individuals representing various vantage points emphasizes concern about safeguards and monitoring the use of these contracts. Although several legal avenues may be open, both theoretical and technical obstacles can block the road to voluntary involuntary treatment. We hope this article will serve as a stimulus for an open exchange about ways to ensure one's right to protect oneself from the consequences of psychosis.

Advance Directives↗
PubMed2002

Sociotropy-dependency and autonomy as predictors of eating disturbance among Canadian female college students.

The authors (a) tested the generalizability of A. Sugarman, D. Quinlan, and L. Devenis's (1982) psychodynamic account of eating disturbances, which posits that overt autonomy strivings associated with eating problems are a defense against unconscious dependency concerns, and (b) evaluated the degree to which autonomy and sociotropy had unique associations with eating disturbances. Canadian female college students (N= 286) completed self-report measures of autonomy, sociotropy, depression, and bulimia as well as the Rorschach Inkblot Test. Findings suggest, contrary to Sugarman and colleagues' psychodynamic account, that experiences of dependency related to self-reported eating pathology do not necessarily lie outside of conscious awareness. Moreover, reported bulimic symptoms were uniquely associated with sociotropy but not autonomy-self-criticism among the participants.

Adolescent↗
PubMed2000

Commentary: value neutrality, moral integrity, and the physician.

The commentator agrees, in part, with Beckwith and Peppin that value neutrality is an illusion, both ethically and legally. He asserts, however, that a physician's moral autonomy does not sanction proselytizing to promote the physician's own values.

Abortion, Legal↗
PubMed2005

"I can put the medicine in his soup, Doctor!".

The practice of covertly administering medication is controversial. Although condemned by some as overly paternalistic, others have suggested that it may be acceptable if patients have permanent mental incapacity and refuse needed treatment. Ethical, legal, and clinical considerations become more complex when the mental incapacity is temporary and when the medication actually serves to restore autonomy. We discuss these issues in the context of a young man with schizophrenia. His mother had been giving him antipsychotic medication covertly in his soup. Should the doctor continue to provide a prescription, thus allowing this to continue? We discuss this case based on the "four principles" ethical framework, addressing the conflict between autonomy and beneficence/non-maleficence, the role of antipsychotics as an autonomy restoring agent, truth telling and the balance between individual versus family autonomy.

Administration, Oral↗
PubMed2005

Autonomy in medical ethics after O'Neill.

Following the influential Gifford and Reith lectures by Onora O'Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O'Neill in recommending a principled version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient-doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring "patient autonomy" when it is, in fact, abrogation of their duty as doctors.

Beneficence↗
PubMed1997

An analysis of CPR decision-making by elderly patients.

Traditionally clinicians have determined their patients' resuscitation status without consultation. This has been condemned as morally indefensible in cases where not for resuscitation (NFR) orders are based on quality of life considerations and when the patient's true wishes are not known. Such instances would encompass most resuscitation decisions in elderly patients. Having previously involved patients in CPR decision-making, we chose formally to explore the reasons behind the choices made. Although the patients were not upset, and readily decided at the time of initial consultation, on later analysing the decision-making we found poor understanding of the procedure, poor recall of information given and in some cases evidence of harm. This may be attributed to impaired decision-making capacity of elderly hospitalised patients as previously shown, or to the discomfort precipitated by having to contemplate the apparent immediacy of cardiac arrest by these patients. We propose that subscribing to autonomy as a general principle needs to be balanced against particular cases where distress may be caused by, or result in, diminished competence and limited autonomy.

Aged↗
PubMed2002

Everyday ethics in an acute psychiatric unit.

The paper begins with a brief statement about the centrality of autonomy or self governance as a core ethical value in the interaction between health care worker and patient. Then there are three stories describing everyday interactions in an acute psychiatric unit. These are used to help unravel ethical issues relating to patient autonomy. Each story is analysed for its ethical components by describing the protagonists' different perspectives, and their reactions to the events. Attention is also paid to institutional policy. Suggestions are made for small changes in both staff behaviour and institutional procedures. Such changes could enhance rather than diminish patient autonomy.

Anecdotes as Topic↗
PubMed1983

A defence of medical paternalism: maximising patients' autonomy.

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper.

Decision Making↗
PubMed2003

Connection and autonomy in the case management relationship.

This study examines the effects of connection and autonomy in the client-case manager relationship on treatment participation, satisfaction with case management, and satisfaction with social life. Three-month case manager ratings of connection were positively correlated with 9-month treatment participation. Six-month client and case manager ratings of connection were positively correlated with improvements in all three outcomes at nine months. Within this time frame, autonomy was positively correlated with treatment participation and satisfaction with case management and negatively correlated with satisfaction with social life. These findings suggest that balancing connection and autonomy in different ways is important in the case management relationship.

Adult↗