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Suspending Do Not Resuscitate (DNR) orders during surgery may undermine a patient's right to self-determination. A Nursing Ethics Committee together with a Clinical Ethics Committee formulate guidelines to consider when suspending or maintaining a patient's DNR order while in the operating room. A patient's autonomy must be recognized as well as the professional responsibilities of surgeons, anesthesiologists and nurses.
Modern medicine is increasingly aware of the significance of patient autonomy in making treatment choices. This would seem to be particularly important where the therapy requested was "voluntary" as in fertility treatment or cosmetic surgery. However, the Hippocratic doctrine "Primum non nocere", seems especially relevant where the treatment sought may have a low chance of a successful outcome or even be life-threatening. Mrs A's case demonstrates the difficulty faced by the physician who wants to maximise her patient's autonomy, but "Above all, do no harm".
Debates about the extent to which patients can and should participate in medical decision making take on new urgency as cost-containment efforts give patients more financial incentives. The Health Care Financing Administration's recent proposal to enable dialysis patients to "price shop" aroused consternation among nephrologists. A working seminar elucidated their fears about professional incomes and about increased patient autonomy.
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Public sentiment in favor of permitting voluntary active euthanasia creates a dilemma for a bioethics rooted in a libertarian notion of autonomy. At stake in the active euthanasia debate is actually a question of power--the individual's assertion of sovereignty over the timing and circumstances of his or her own death. Also at stake is society's unwillingness to impose a conception of the good--and a good dying--on individuals whose personal values and conceptions of the good may differ. In order both to reject voluntary active euthanasia and to affirm the patient's right to forgo life-sustaining treatment, some societal conception of the good must be developed and agreed upon to counter unbridled claims of individual self-sovereignty over dying. Pragmatic arguments alone, such as the need to maintain confidence in the doctor-patient relationship, will not be sufficient.
We present a family who sought prenatal diagnosis in order to bear a healthy child to serve as an HLA-identical bone marrow donor for their son affected with Wiskott-Aldrich syndrome. They intended to abort HLA-incompatible fetuses who would have been unsuitable bone marrow donors. This case led us to conclude that prenatal diagnosis should not be used to benefit a third party or facilitate the conception or abortion of a fetus for the purpose of generating an organ for transplantation. The limits of parental autonomy and physician responsibility are discussed.
Surgery offers patients the chance to improve the quality and longevity of their lives, but surgery and anesthesia are not without risks. Patients should have the opportunity to make informed choices about the risks they take with respect to their health care. Perioperative nurses must be knowledgeable about advance directives and the implications they have for surgical care, and they must support patient autonomy by respecting the choices and decisions patients make about their care.
Two theoretical approaches to interpersonal experiences and behavior are empirically related to each other: Structural Analysis of Social Behavior (SASB) and attachment theory. The focus is on the most important relationships during life-span: relationships with mother and father in childhood, which were measured retrospectively, and romantic relationships in adulthood. 93 outpatients of a psychosomatic clinic took part in the study. Self-report measures were used to assess SASB-dimensions affiliation and autonomy and attachment variables (Intrex short form, Short measure of attachment to parents, Bochum Adult Attachment Questionnaire). Affiliation was strongly related to attachment to mother, father and romantic partner. Subjects classified as secure with respect to attachment to parents reported higher levels of affiliation than subjects classified as anxious or avoidant. Correspondingly, affiliation was negatively correlated with avoidance and anxiety in adult attachment to the romantic partner. On the other hand, autonomy was shown to be unrelated to attachment variables. Results indicate that the SASB-dimension affiliation and attachment security are closely associated.
Philosophical discussions of the morality of suicide have tended to focus on its justifiability from an agent's point of view rather than on the justifiability of attempts by others to intervene so as to preserve it. This paper addresses questions of suicide intervention within a broadly Kantian perspective. In such a perspective, a chief task is to determine the motives underlying most suicidal behaviour. Kant wrongly characterizes this motive as one of self-love or the pursuit of happiness. Psychiatric and scientifc evidence suggests that suicide is instead motivated by nihilistic disenchantment with the possibility of happiness which, at its apex, results in the loss of the individual's conception of her practical identity. Because of this, methods of intervention that appeal to agents' happiness, while morally benign, will prove ineffective in forestalling suicide. At the same time, more aggressive methods violate the Kantian concern for autonomy. This apparent dilemma can be resolved by seeing suicide intervention as an action undertaken in non-ideal circumstances, where otherwise unjustified manipulation, coercion, or paternalism are morally permitted.
In response to the common belief that paternalism directed toward a competent patient necessarily transgresses the patient's right of self-determination and is therefore morally suspect, the authors argue that such a general view fails to appreciate the complexity of the patient/physician relationship as it is manifested in various clinical settings. It is the authors' contention that some strongly paternalistic acts may fail to violate the patient's right of autonomy, that other such acts may actually be a function of respect for patient autonomy, and that others may only suspend or momentarily infringe upon patient autonomy. They conclude that if these instances of paternalism differ from the classical examples of strong paternalism, then so also should the moral appraisal.
Focusing on the notable 1964 case of Application of the President and Directors of Georgetown College and subsequent cases, the author explores the connections between parents' and children's interests in ways which tend to support a parent's autonomy and hence a parent's refusal of life-sustaining treatment.
The potential role of the psychotherapist as ethical interventionist is considered with reference to a patient who presented with a writing block. The case for the therapist to act paternalistically is followed by the counterargument which revolves around the respect for autonomy. A bridge between these two opposing positions is then offered which depends on viewing informed consent as a dynamic process. As part of this procedure it is made clear that while autonomy is the desired end-state of psychotherapy, it is not the be all and end all of treatment. Therapy is necessarily value-laden since it aims for the enhancement of the patient's state of autonomy; it is value-free inasmuch as the therapist desists from guiding the patient in how she should live her life.
BACKGROUND: Patient autonomy has gradually replaced physician paternalism as an ethical ideal. However, in a medical context, the principle of individual autonomy has different meanings. More knowledge is needed about what is and should be an appropriate understanding of the concept of patient autonomy in clinical practice. AIM: To challenge the traditional concept of patient autonomy by applying a discourse analysis to the issue. METHOD: A qualitative case study approach with material from one consultation. The discourse is interpreted according to pragmatic and text-linguistic principles and provides the basis of a theoretical discussion of different concepts of patient autonomy. RESULTS: The consultation transcript illustrates how the patient's wishes can be respected in real life. The patient, her husband and the doctor are all involved in the discourse dynamics, governed by the subject matter, namely her mental illness. CONCLUSION: We suggest a dynamic and dialogue-based conception of autonomy as adequate for clinical purposes. These perspectives, based on mutual understanding, take communication between patient and doctor as their starting point. According to this approach, autonomy requires a genuine dialogue, an interpersonal mode of being which we choose to call "authentic interaction".
There has been a rapid growth in the number of articles using Internet data sources to illuminate health behavior. However, little has been written about the ethical considerations of online research, especially studies involving data from Internet discussion boards. Guidelines are needed to ensure ethical conduct. In this article, the authors examine how a youth-focused research program negotiated ethical practices in the creation of its comprehensive health site and online message board. They address three situations in which ethical predicaments arose: (a) enrolling research participants, (b) protecting participants from risk or harm, and (c) linking public and private data. Drawing on the ethical principles of autonomy, nonmaleficence, justice, and beneficence, the authors present practical guidelines for resolving ethical dilemmas in research on Internet communities.
BACKGROUND: It is not currently known what is the patient's viewpoint of a "good" physician. We set out to define patient's priorities regarding different physician's attributes in 3 domains important in medical care. METHODS: Patients hospitalized or attending clinics at a large teaching hospital selected the 4 attributes that they considered most important out of 21 listed arbitrarily in a questionnaire. The questionnaire included 7 items each in the domains of patient autonomy, professional expertise and humanism. RESULTS: Participating patients (n = 445, mean age 57.5 +/- 16 years) selected professional expertise (50%), physician's patience and attentiveness (38% and 30%, respectively), and informing the patient, representing the patient's interests, being truthful and respecting patient's preferences (25-36% each) as the most essential attributes. Patient's selections were not significantly influenced by different demographic or clinical background. Selections of attributes in the domain of patient's autonomy were significantly more frequent and this was the preferred domain for 31% and as important as another domain for 16%--significantly more than the domain of professional expertise (P = 0.008), and much more than the domain of humanism and support (P < 0.0005). CONCLUSIONS: Patients studied want their physicians to be highly professional and expert clinicians and show humaneness and support, but their first priority is for the physician to respect their autonomy.
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Explore the source record for details and available documents.