If you’re planning to study medicine, there are a lot of principles and rules you’ll need to understand. One set of these is the Four Pillars of Medical Ethics, which help to ensure the best possible outcome for all patients under our care.
One of these pillars is Autonomy, which plays a crucial part in ensuring patients are getting both the care they want and need. In this guide, we’ll explore this principle in detail and explore case studies in the context of it to understand how we should act as medical professionals
Written by Emma Francis-Gregory
What is Autonomy?
The definition of autonomy is as follows:
Autonomy – the right or condition of self-government.
In the context of medicine, autonomy is one of the four core pillars of medical ethics and also has significant legal implications for practice. Per the pillar of autonomy, patients have the ultimate decision-making responsibility regarding their care and should be given all the information necessary to make informed decisions. Performing medical treatments or examinations without patient consent is termed ‘battery’ and is a criminal offence.
Whilst the concept itself is simple, applying this in clinical practice is often challenging, and can lead to disagreements between patients, their families, and the medical teams caring for them.
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Does Autonomy Apply to Everyone?
Whether or not a patient can make decisions regarding their care is dependent on whether they have capacity. Capacity refers to a patient’s ability to make an informed decision using the information provided to them by the team involved in their care. In order to have capacity, patients must be able to:
1. Understand the information given to them regarding their care and the different options available to them
2. Retain this information for long enough to make a decision
3. Use and apply the information to make an informed decision regarding their care
4. Communicate their decision
If a patient is unable to do any one of the above, they are deemed to lack capacity. All adult patients must be assumed to have capacity until proven otherwise – you can never assume that a patient does not have capacity, regardless of any other conditions they have that may impact their cognitive function.
Furthermore, all reasonable measures must be taken to support patients in the above – for example, patients unable to speak English should not be assumed to lack capacity if they are unable to understand the information provided to them or communicate their decision due to the language barrier. Instead, a colleague who is fluent in their native language or the NHS translator service should be used.
Capacity is both time and decision-specific. At a given time, a patient may have the capacity to make a decision regarding pain relief but not concerning surgery. Similarly, a patient may have capacity upon admission, but lose capacity if they deteriorate and are no longer able to fulfil the above criteria.
If a patient lacks capacity, their care team can make decisions on their behalf taking into consideration the patient’s wishes if expressed previously, input from their family, and the likely outcomes of the treatment. Decisions made on the patient’s behalf must be in their best interests under the principle of Beneficence.
Why is Autonomy Important?
As highlighted, autonomy is essential from a legal and ethical perspective. However, there are also a number of additional reasons why autonomy is a key principle in medical practice:
Increased Compliance & Cooperation
Patients are more likely to comply with their treatments and medications if they feel involved in their care and therefore are likely to have better outcomes.
Increased Doctor Trust
Patients are likely to feel more secure in the patient-doctor relationship if they are listened to, given all the relevant information, and supported in the best decision for their care. This also means that they are more likely to present to their doctor if they have any issues in the future, as they know they will be supported and cared for.
Empowers Patients
Autonomy allows patients to engage with healthcare more broadly. If patients engage in their care via the decision-making process, they are more likely to engage in other areas and may make healthier decisions elsewhere to improve their general health.
As well as these benefits, it’s important to consider that the pillar of autonomy is very much supported by beneficence and non-maleficence. It is in the patient’s best interests to take ownership of their health and their body and to make informed decisions that they are happy with.
Additional Considerations For Autonomy
Here are some additional things to consider when discussing and implementing the principle of autonomy:
Challenges of Autonomy
Autonomy can often pose challenges for medical professionals, as patients may refuse the best possible treatment due to a number of reasons. Whether it’s down to fear of treatment, a desire to no longer live, religious beliefs or a misunderstanding of the situation, patients will often not choose what you have deemed the best course of action.
The important thing to remember is that you cannot force treatment on to anyone who is deemed to have capacity, so your objective is to properly educate, reassure or otherwise convince them to take the best course of action in a non-judgmental, non-forceful manner.
If an agreement can ultimately not be reached, you will most likely have to fulfil the patient’s wishes (although serious situations will require consultation from others in your team).
Patient Coercion
Consider if there is a possibility the patient is being coerced or is being pressured by friends, family or their partner. A decision made by a patient who is being pressured by others is not autonomous, as the ultimate choice should belong to the patient themselves.
Required Information
Consider whether the doctor has given the patient all the necessary information to make an informed decision. Autonomy involves supporting patients to make a fully informed decision, which is not possible if a clinician withholds important information. Any decision made without crucial information (including details of the risks, benefits, and feasible alternatives) is not autonomous.
Patient Demands
Remember that autonomy does not give patients the right to demand treatments from doctors. A doctor is not obligated to provide a treatment that they do not think is clinically appropriate just because a patient requests it – however, the patient also has the right to see another doctor whom they believe is more likely to agree with the request.
Guardianship
If a patient does not have capacity, consider if anyone has the legal responsibility to make decisions on their behalf. For those under 18, this will be their parent or guardian, but adults may also have a lasting power of attorney appointed for situations in which they cannot make decisions for themselves.
Autonomy In Interviews
In ethical scenarios during interviews, it may also be appropriate to consider resource allocation. Whilst this is predominantly considered under the pillar of justice, it may be appropriate to take into account the limited resources available in a situation whereby a patient is demanding a treatment that someone else may need more.
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Autonomy Medical Case Studies
Now that we understand more about the principle of Autonomy, it’s time to look at some case studies where it plays a key role. Scenarios like these may come up in your Panel interviews and MMIs, so be sure to read these carefully and try to understand the explanations provided.
Autonomy Case Study 1
James is a 37-year old male presenting to A&E following a road traffic collision. Due to the injuries sustained in the accident, James has lost a significant volume of blood and his care team have informed him that they would like to administer a blood transfusion and that not doing so is likely to result in his death.
James explains that he is a practising Jehovah’s Witness and believes that the soul resides in the blood. It is against his faith to accept any blood products, and he says that he understands that his decision to refuse the transfusion means that he is likely to die but he will not accept the blood under any circumstances.
Consider the application of the principle of autonomy to James’ case.
James is an adult and has capacity – he has understood the information provided to him, retained it, applied it, and communicated his decision back to his care team. Although the doctor believes that James’ decision is unwise and does not agree with it, James is an adult with capacity, and therefore his choices must be honoured.
Additionally, it is important to note that making what you consider to be an unwise decision does not mean that a patient lacks capacity – the fact that James is likely to die as a result of his decision does not mean that the doctors can override his choices (provided he has capacity).
Autonomy Case Study 2
Hannah is a 19-year old woman who has recently been admitted to an in-patient eating disorder unit due to anorexia. Her care team are growing increasingly concerned about her lack of food intake, and her heart is now showing signs of failure due to the low caloric intake.
They have informed her that if she does not eat, they will have to provide her with enteral nutrition administered via a feeding tube against her wishes as they are concerned her heart will stop. Hannah insists that she is not unwell, and that it violates her autonomy to force her to receive nutrition against her will.
Consider the application of the principle of autonomy to Hannah’s case.
Although on the surface Hannah’s case is very similar to James’, there is an additional complexity here with regards to Hannah’s poor mental health. Her insistence that she is not unwell despite suffering from life-threatening malnutrition suggests that she is not of sound mind to make a fully-informed decision regarding her care.
Her eating disorder is impairing her judgement and is causing a distorted perception of her health. As such, it would be appropriate for her care team to administer treatment against her wishes in this case, as she is unable to use the information provided to her to make an informed decision.
Autonomy Case Study 3
Sarah is a 29-year old woman attending her GP surgery. She has been suffering with back pain for the past few weeks and wishes to receive medication to ease this. The doctor agrees and offers to prescribe co-codamol to ease her pain.
However, Sarah states that she wants morphine. The doctor explains that morphine is usually reserved for pain relief when other medications have failed to control the pain, but Sarah is adamant that she wants morphine.
Consider the application of the principle of autonomy to Sarah’s case.
Sarah is an adult and has not given cause to doubt her capacity. As such, she retains autonomy and is able to make informed decisions regarding her care and does not have to take the medication suggested by her doctor if she does not wish to.
However, autonomy does not allow patients to demand treatments, and her GP is not obligated to prescribe a treatment they do not believe is medically appropriate despite Sarah’s demands. Sarah is welcome to discuss her care with another GP and obtain a second opinion, but her insistence on being given morphine does not mean that she is entitled to receive it if the doctor believes it is not appropriate, regardless of capacity.
I hope this guide has been helpful to you and that you now understand this principle better. If you want to learn about specific ethical topics that relate to Autonomy, be sure to check out our collection of medical ethics guides. You can also learn more about the med school interview process as a whole with our medicine interview guides.
There’s a lot of ground to cover within these topics, so you may also want to seek out additional support from medicine experts. If so, consider 6med’s Interview Tutoring Bundles or Medicine Mastery Bundles, each of which pairs you with a medicine tutor who will guide you through whatever you need to know. You’ll also get access to comprehensive resources and live crash courses, making them the ultimate preparation package. Learn more about them today or book a free consultation to speak with our friendly team!
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