Editing Autonomy (section)

==Medicine==
In a [[medicine|medical]] context, respect for a patient's personal autonomy is [[medical ethics|considered]] one of many fundamental ethical principles in medicine.<ref>{{Cite journal|last=Varelius|first=Jukka|date=December 2006|title=The value of autonomy in medical ethics|journal=Medicine, Health Care and Philosophy|volume=9|issue=3|pages=377–388|doi=10.1007/s11019-006-9000-z|issn=1386-7423|pmc=2780686|pmid=17033883}}</ref> Autonomy can be defined as the ability of the person to make his or her own decisions. This faith in autonomy is the central premise of the concept of [[informed consent]] and [[shared decision making]]. This idea, while considered essential to today's practice of medicine, was developed in the last 50 years. According to [[Tom Beauchamp]] and [[James Childress]] (in ''Principles of Biomedical Ethics''), the [[Doctors' Trial|Nuremberg trials]] detailed accounts of horrifyingly exploitative medical "experiments" which violated the subjects' physical integrity and personal autonomy.<ref>{{Cite book|title=Principles of biomedical ethics|last=Beauchamp|first=Tom L.|date=2013|publisher=Oxford University Press|others=Childress, James F.|isbn=978-0199924585|edition=7th |location=New York|oclc=808107441}}</ref> These incidences prompted calls for safeguards in [[medical research]], such as the [[Nuremberg Code]] which stressed the importance of voluntary participation in medical research. It is believed that the Nuremberg Code served as the premise for many current documents regarding research ethics.<ref>{{Cite journal|last=Fischer|first=Bernard A|date=January 2006|title=A Summary of Important Documents in the Field of Research Ethics|journal=Schizophrenia Bulletin|volume=32|issue=1|pages=69–80|doi=10.1093/schbul/sbj005|issn=0586-7614|pmc=2632196|pmid=16192409}}</ref>

Respect for autonomy became incorporated in health care and patients could be allowed to make personal decisions about the health care services that they receive.<ref>{{Cite journal|last=Leo|first=Raphael J.|date=October 1999|title=Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians|journal=Primary Care Companion to the Journal of Clinical Psychiatry|volume=1|issue=5|pages=131–141|issn=1523-5998|pmid=15014674|pmc=181079|doi=10.4088/PCC.v01n0501}}</ref> Notably, autonomy has several aspects as well as challenges that affect health care operations. The manner in which a patient is handled may undermine or support the autonomy of a patient and for this reason, the way a patient is communicated to becomes very crucial. A good relationship between a patient and a health care practitioner needs to be well defined to ensure that autonomy of a patient is respected.<ref>{{cite book|last1=Riis|first1=A.H|title=Autonomy, culture and healthcare}}</ref> Just like in any other life situation, a patient would not like to be under the control of another person. The move to emphasize respect for patient's autonomy rose from the vulnerabilities that were pointed out in regards to autonomy.

However, autonomy does not only apply in a research context. Users of the health care system have the right to be treated with respect for their autonomy, instead of being dominated by the [https://books.google.com/books?id=x1DNCNNX8AIC&q=silent+world+of+doctor+and+patient physician].<ref>{{Cite web |last=Gandhi |first=Akash |title=Medical Ethics - The Principles |url=https://www.theukcatpeople.co.uk/application-guide/interview/answering-medical-ethics-interview-questions |access-date=28 February 2024 |website=www.theukcatpeople.co.uk}}</ref> This is referred to as [[paternalism]]. While paternalism is meant to be overall good for the patient, this can very easily interfere with autonomy.<ref>{{cite journal|last1=Sandman|first1=Lars|title=Adherence, Shared Decision-Making and Patient Autonomy|journal=Medicine, Health Care and Philosophy|date=2012|volume=15|issue=2|pages=115–27|doi=10.1007/s11019-011-9336-x|pmid=21678125|s2cid=30120495}}</ref> Through the [[therapeutic relationship]], a thoughtful dialogue between the client and the physician may lead to better outcomes for the client, as he or she is more of a participant in [[decision-making]].

There are many different definitions of autonomy, many of which place the individual in a social context. Relational autonomy, which suggests that a person is defined through their relationships with others, is increasingly considered in medicine and particularly in critical<ref>{{Cite journal |last1=Grignoli |first1=Nicola |last2=Di Bernardo |first2=Valentina |last3=Malacrida |first3=Roberto |date=2018-10-11 |title=New perspectives on substituted relational autonomy for shared decision-making in critical care |journal=Critical Care |volume=22 |issue=1 |page=260 |doi=10.1186/s13054-018-2187-6 |issn=1364-8535 |pmc=6182794 |pmid=30309384 |doi-access=free }}</ref> and end-of-life care.<ref>{{Cite journal |last1=Gómez-Vírseda |first1=Carlos |last2=de Maeseneer |first2=Yves |last3=Gastmans |first3=Chris |date=2019-10-26 |title=Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature |journal=BMC Medical Ethics |volume=20 |issue=1 |pages=76 |doi=10.1186/s12910-019-0417-3 |issn=1472-6939 |pmc=6815421 |pmid=31655573 |doi-access=free }}</ref> Supported autonomy<ref name="library.yorku.ca">{{cite web|url=https://www.library.yorku.ca/find/Record/2376624|title=Exemplaires: Consent and capacity in Ontario's civil mental|archive-url=https://web.archive.org/web/20150524174134/https://www.library.yorku.ca/find/Record/2376624|archive-date=2015-05-24|url-status=live|access-date=2015-05-24}}</ref> suggests instead that in specific circumstances it may be necessary to temporarily compromise the autonomy of the person in the short term in order to preserve their autonomy in the long-term. Other definitions of the autonomy imagine the person as a contained and self-sufficient being whose rights should not be compromised under any circumstance.<ref>{{cite web|url=http://www.goodreads.com/book/show/634749.The_Inner_Citadel|title=The Inner Citadel|archive-url=https://web.archive.org/web/20150924145857/http://www.goodreads.com/book/show/634749.The_Inner_Citadel|archive-date=2015-09-24|url-status=live|access-date=2015-05-24}}</ref>

There are also differing views with regard to whether modern health care systems should be shifting to greater patient autonomy or a more paternalistic approach. For example, there are such arguments that suggest the current patient autonomy practiced is plagued by flaws such as misconceptions of treatment and cultural differences, and that health care systems should be shifting to greater paternalism on the part of the physician given their expertise.<ref>{{Cite journal|last=Caplan|first=Arthur L|date=2014|title=Why autonomy needs help|journal=Journal of Medical Ethics|volume=40|issue=5|pages=301–302|issn=0306-6800|jstor=43282987|doi=10.1136/medethics-2012-100492|pmid=22337604|s2cid=207010293}}</ref> On the other hand, other approaches suggest that there simply needs to be an increase in relational understanding between patients and health practitioners to improve patient autonomy.<ref>{{Cite journal|last1=Entwistle|first1=Vikki A.|last2=Carter|first2=Stacy M.|last3=Cribb|first3=Alan|last4=McCaffery|first4=Kirsten|author-link4=Kirsten McCaffery|date=July 2010|title=Supporting Patient Autonomy: The Importance of Clinician-patient Relationships|journal=Journal of General Internal Medicine|volume=25|issue=7|pages=741–745|doi=10.1007/s11606-010-1292-2|issn=0884-8734|pmc=2881979|pmid=20213206}}</ref>

One argument in favor of greater patient autonomy and its benefits is by Dave deBronkart, who believes that in the technological advancement age, patients are capable of doing a lot of their research on medical issues from their home. According to deBronkart, this helps to promote better discussions between patients and physicians during hospital visits, ultimately easing up the workload of physicians.<ref name=":0">{{Cite journal|last=deBronkart|first=Dave|date=2015|title=From patient centred to people powered: autonomy on the rise|journal=BMJ: British Medical Journal|volume=350|issn=0959-8138|jstor=26518242}}</ref> deBronkart argues that this leads to greater patient empowerment and a more educative health care system.<ref name=":0" /> In opposition to this view, technological advancements can sometimes be viewed as an unfavorable way of promoting patient autonomy. For example, self-testing medical procedures which have become increasingly common are argued by Greaney et al. to increase patient autonomy, however, may not be promoting what is best for the patient. In this argument, contrary to deBronkart, the current perceptions of patient autonomy are excessively over-selling the benefits of individual autonomy, and is not the most suitable way to go about treating patients.<ref name=":3">{{Cite journal|last1=Greaney|first1=Anna-Marie|last2=O'Mathúna|first2=Dónal P.|last3=Scott|first3=P. Anne|date=2012-11-01|title=Patient autonomy and choice in healthcare: self-testing devices as a case in point|journal=Medicine, Health Care and Philosophy|volume=15|issue=4|pages=383–395|doi=10.1007/s11019-011-9356-6|pmid=22038653|s2cid=915117|issn=1572-8633|url=http://doras.dcu.ie/19339/1/AMG_Patient_autonomy_and_choice_in_healthcare_Self-testing_devices_as_a_case_in_point_Revised_Manuscript__MHEP.pdf|access-date=2019-06-16|archive-date=2017-09-22|archive-url=https://web.archive.org/web/20170922024806/http://doras.dcu.ie/19339/1/AMG_Patient_autonomy_and_choice_in_healthcare_Self-testing_devices_as_a_case_in_point_Revised_Manuscript__MHEP.pdf|url-status=live}}</ref> Instead, a more inclusive form of autonomy should be implemented, relational autonomy, which factors into consideration those close to the patient as well as the physician.<ref name=":3" /> These different concepts of autonomy can be troublesome as the acting physician is faced with deciding which concept he/she will implement into their clinical practice.<ref>{{Cite journal|last1=Ross|first1=Lainie Friedman|last2=Walter|first2=Jennifer K.|date=2014-02-01|title=Relational Autonomy: Moving Beyond the Limits of Isolated Individualism|url=https://pediatrics.aappublications.org/content/133/Supplement_1/S16|journal=Pediatrics|volume=133|issue=Supplement 1|pages=S16–S23|doi=10.1542/peds.2013-3608D|issn=0031-4005|pmid=24488536|doi-access=free|access-date=2019-04-14|archive-date=2019-04-13|archive-url=https://web.archive.org/web/20190413172948/https://pediatrics.aappublications.org/content/133/Supplement_1/S16|url-status=live|url-access=subscription}}</ref> It is often references as one of the four pillars of medicine, alongside beneficence, justice and nonmaleficence<ref>{{Cite web |title=Medical Ethics Interview Questions Guide – {{!}} Interview |url=https://www.theukcatpeople.co.uk/application-guide/interview/answering-medical-ethics-interview-questions |url-status=live |archive-url=https://web.archive.org/web/20230207003454/https://www.theukcatpeople.co.uk/application-guide/interview/answering-medical-ethics-interview-questions |archive-date=2023-02-07 |access-date=2023-02-07 |website=www.theukcatpeople.co.uk |language=en}}</ref>

Autonomy varies and some patients find it overwhelming especially the minors when faced with emergency situations. Issues arise in emergency room situations where there may not be time to consider the principle of patient autonomy. Various ethical challenges are faced in these situations when time is critical, and patient consciousness may be limited. However, in such settings where informed consent may be compromised, the working physician evaluates each individual case to make the most professional and ethically sound decision.<ref name=":4">{{Cite journal|last1=Muskens|first1=Ivo S.|last2=Gupta|first2=Saksham|last3=Robertson|first3=Faith C.|last4=Moojen|first4=Wouter A.|last5=Kolias|first5=Angelos G.|last6=Peul|first6=Wilco C.|last7=Broekman|first7=Marike L. D.|date=2019-01-26|title=When Time Is Critical, Is Informed Consent Less So? A Discussion of Patient Autonomy in Emergency Neurosurgery|journal=World Neurosurgery|volume=125|pages=e336–e340|doi=10.1016/j.wneu.2019.01.074|issn=1878-8769|pmid=30690144|url=https://www.repository.cam.ac.uk/handle/1810/288856|hdl=1887/3195421|s2cid=59339055|hdl-access=free|access-date=2019-06-16|archive-date=2019-06-16|archive-url=https://web.archive.org/web/20190616194605/https://www.repository.cam.ac.uk/handle/1810/288856|url-status=live}}</ref> For example, it is believed that neurosurgeons in such situations, should generally do everything they can to respect patient autonomy. In the situation in which a patient is unable to make an autonomous decision, the neurosurgeon should discuss with the surrogate decision maker in order to aid in the decision-making process.<ref name=":4" /> Performing surgery on a patient without informed consent is in general thought to only be ethically justified when the neurosurgeon and his/her team render the patient to not have the capacity to make autonomous decisions. If the patient is capable of making an autonomous decision, these situations are generally less ethically strenuous as the decision is typically respected.<ref name=":4" />

Not every patient is capable of making an autonomous decision. For example, a commonly proposed question is at what age children should be partaking in treatment decisions.<ref name=":5">{{Cite news|url=https://www.nytimes.com/2016/09/19/well/family/when-should-children-take-part-in-medical-decisions.html|title=When Should Children Take Part in Medical Decisions?|last1=Klass|first1=Perri|date=2016-09-20|work=The New York Times|access-date=2019-04-21|issn=0362-4331|archive-date=2019-04-02|archive-url=https://web.archive.org/web/20190402185953/https://www.nytimes.com/2016/09/19/well/family/when-should-children-take-part-in-medical-decisions.html|url-status=live}}</ref> This question arises as children develop differently, therefore making it difficult to establish a standard age at which children should become more autonomous.<ref name=":5" /> Those who are unable to make the decisions prompt a challenge to medical practitioners since it becomes difficult to determine the ability of a patient to make a decision.<ref>{{cite journal|last1=Cole|first1=Clare|last2=Wellard|first2=Sally|last3=Mummery|first3=Jane|title=Problematising autonomy and advocacy in nursing|journal=Nursing Ethics|volume=21|issue=5|pages=576–582|doi=10.1177/0969733013511362|pmid=24399831|year=2014|s2cid=10485758}}</ref> To some extent, it has been said that emphasis of autonomy in health care has undermined the practice of health care practitioners to improve the health of their patient as necessary. The scenario has led to tension in the relationship between a patient and a health care practitioner. This is because as much as a physician wants to prevent a patient from suffering, they still have to respect autonomy. Beneficence is a principle allowing physicians to act responsibly in their practice and in the best interests of their patients, which may involve overlooking autonomy.<ref>{{Cite journal|last=MacKenzie|first=C. Ronald|date=September 2009|title=What Would a Good Doctor Do? Reflections on the Ethics of Medicine|journal=HSS Journal|volume=5|issue=2|pages=196–199|doi=10.1007/s11420-009-9126-7|issn=1556-3316|pmc=2744764|pmid=19626379}}</ref> However, the gap between a patient and a physician has led to problems because in other cases, the patients have complained of not being adequately informed.

The seven elements of informed consent (as defined by Beauchamp and Childress) include threshold elements (competence and voluntariness), information elements (disclosure, recommendation, and understanding) and consent elements (decision and authorization).<ref>[https://books.google.com/books?id=b6w7V7gCkSIC&q=informed+consent Informed Consent : Legal Theory and Clinical Practice: Legal Theory and ...] {{Webarchive|url=https://web.archive.org/web/20240219171942/https://books.google.com/books?id=b6w7V7gCkSIC&q=informed+consent#v=snippet&q=informed%20consent&f=false |date=2024-02-19 }} – Schools of Law and Medicine Jessica W. Berg Assistant Professor of Law and Bioethics Case Western Reserve University, Paul S. Appelbaum A. F. Zeleznik Distinguished Professor and Chair University of Massachusetts, Medical School and Director of the Center for Mental Health Services Research Charles W. Lidz Research Professor of Psychiatry University of Massachusetts, Center for Bioethics and Health Law University of Pittsburgh Lisa S. Parker Associate Professor and Director of Graduate Education – Google Books. Retrieved on 2013-07-12.</ref> Some philosophers such as Harry Frankfurt consider Beauchamp and Childress criteria insufficient. They claim that an action can only be considered autonomous if it involves the exercise of the capacity to form higher-order values about desires when acting intentionally.<ref>Mappes Thomas, A., and David DeGrazia. ''Biomedical Ethics''. (2006). pp. 54–55 {{ISBN?}}</ref> What this means is that patients may understand their situation and choices but would not be autonomous unless the patient is able to form value judgements about their reasons for choosing treatment options they would not be acting autonomously.

In certain unique circumstances, government may have the right to temporarily override the right to [[bodily integrity]] in order to preserve the life and well-being of the person. Such action can be described using the principle of "supported autonomy",<ref name="library.yorku.ca"/> a concept that was developed to describe unique situations in mental health (examples include the [[forced feeding]] of a person dying from the [[eating disorder]] [[anorexia nervosa]], or the temporary treatment of a person living with a [[psychotic disorder]] with [[antipsychotic medication]]). While controversial, the principle of supported autonomy aligns with the role of government to protect the life and liberty of its citizens. Terrence F. Ackerman has highlighted problems with these situations, he claims that by undertaking this course of action physician or governments run the risk of misinterpreting a conflict of values as a constraining effect of illness on a patient's autonomy.<ref>Mappes Thomas, A., and David DeGrazia. ''Biomedical Ethics.'' (2006). p. 62</ref>

Since the 1960s, there have been attempts to increase patient autonomy including the requirement that physician's take bioethics courses during their time in medical school.<ref>{{cite journal|last1=Pilnick|first1=Alison|last2=Dingwall|first2=Robert|title=On the Remarkable Persistence of Asymmetry in Doctor/Patient Interaction: A Critical Review|journal=Social Science & Medicine|date=April 2011|volume=72|issue=8|pages=1374–1382|doi=10.1016/j.socscimed.2011.02.033|pmid=21454003}}</ref> Despite large-scale commitment to promoting patient autonomy, public mistrust of medicine in developed countries has remained.<ref>O'neill, Onora. ''Autonomy and Trust in Bioethics''. Cambridge University Press, 2002. p. 3 {{ISBN?}}</ref> [[Onora O'Neill]] has ascribed this lack of trust to medical institutions and professionals introducing measures that benefit themselves, not the patient. O'Neill claims that this focus on autonomy promotion has been at the expense of issues like distribution of healthcare resources and public health.

One proposal to increase patient autonomy is through the use of support staff. The use of support staff including medical assistants, physician assistants, nurse practitioners, nurses, and other staff that can promote patient interests and better patient care.<ref>{{cite journal|last1=Sheather|first1=Julian|title=Patient Autonomy|journal=Student BMJ|date=2011|volume=19}}</ref> Nurses especially can learn about patient beliefs and values in order to increase informed consent and possibly persuade the patient through logic and reason to entertain a certain treatment plan.<ref>{{cite journal|last1=Charles|first1=Sonya|title=The Moral Agency of Institutions: Effectively Using Expert Nurses to Support Patient Autonomy|journal=Journal of Medical Ethics|date=2017|volume=43|issue=8|pages=506–509|doi=10.1136/medethics-2016-103448|pmid=27934774|s2cid=11731579}}</ref><ref>{{cite journal|last1=Humphreys|first1=Sally|title=Patient Autonomy|journal=British Journal of Perioperative Nursing|date=January 2005|volume=15|issue=1|pages=35–38, 40–41, 43|doi=10.1177/175045890501500103|pmid=15719905|s2cid=11528632}}</ref> This would promote both autonomy and beneficence, while keeping the physician's integrity intact. Furthermore, Humphreys asserts that nurses should have professional autonomy within their scope of practice (35–37). Humphreys argues that if nurses exercise their professional autonomy more, then there will be an increase in patient autonomy (35–37).