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Autonomy & Agency

Fundamentals


The patient is at the center of the medical system

The great American experiment, as de Tocqueville called it, has proven one theory to be remarkably true: systems work best when individual rights are prioritized and protected. Whether it be the right to associate or religious liberty, unleashing the power of the human person can accomplish incredible things.

This principle rightly takes its place at the heart of the American medical system. The way that we think about and deliver medicine is patient focused. To be sure, there is a financial motivation behind this arrangement. If a patient does not feel that a provider cares about them as a person, they are likely to find care elsewhere. However, I believe that there’s a deeper motivation. Medicine is intrinsically compassionate. Caring for and helping people is foundational to the practice and delivery of medicine. The patient is more than a condition, disorder, or deficiency; they are a human person seeking a better quality of life.

The Anatomy of Autonomy
Codified in law and in federal and state regulations, is the right to informed consent. In order for a course of treatment to be pursued, a patient must be educated on the the risks, benefits and alternatives and allowed to make the decision. Nothing can be forced on an unwilling patient, nor can anything be done to subvert this right.

While this may be the law, there are still barriers in the health system. The education level of the patient serves as one example. Do they have the ability to understand and make a competent decision? Is the provider deviating from the standard of care without the knowledge of the patient? Is an additional procedure being performed without the informed consent of the patient? These barriers are real problems when a provider egregiously violates trust. The malpractice of a few individuals should not reflect on the medical community as a whole, who dedicate their lives to improving the human experience.

The law demands that patients understand and freely consent to medical treatments. However, more important than any legal requirement is the demand of humanity to treat people ethically.

Agency
There are times in life when we are unable to competently make our own medical decisions. These times include our youth before the age of majority, after a traumatic injury, or in our senior years. In these times in which we are most vulnerable and most active in the medical system, there are legal avenues for granting agency to a trusted family member or friend for our medical decisions.

Acting as the agent making healthcare decisions is no easy task. Consider a child who must make the heart wrenching choice to end life-support of their parent. Consider a parent who must study and comprehend the risks and benefits of a surgery for their toddler. This is a grave responsibility that must never be taken lightly.

When agency is granted in a legally permissible way, the providers and medical care team must do all that they can to educate and support the competent decisions of the agent. The agent, too, has their own set of responsibilities. They must act within their defined role and always in accord with the patient’s wishes. The best way for an agent to make medical decisions is if there is an instrument available for reference, such as an advanced directive. The role becomes truly challenging if the patient has no wishes recorded for reference. In these cases, the agent should make an educated guess based on the principles of the patient, combined with the medical facts at the time.

Patient Autonomy vs. Physician Autonomy
There is a distinction that must be made. The autonomy of the patient cannot and shall not abridge the physician’s autonomy. The physician has a duty to the patient to practice medicine in accord with their set of ethics and conscience rights. This is a reciprocal non-offensive principle; the patient cannot compel the physician to act. For example, a patient cannot compel a physician to prescribe a dose of pharmaceuticals for the purpose of suicide. In the same way, a physician cannot breach the autonomy of a patient by prescribing the dose against the patient’s wishes.

The patient is at the center of the medical system. Their right to make informed decisions about treatment without interference or coercion is paramount. The patient’s agent must act within their defined role to the best of their ability. Finally, neither the patient nor the physician may abridge one another’s autonomy by forcing an action on the other without mutual consent.


About the Author

CHET COLLINS is a full-time sidekick to three small humans. He gets his best creative work done during their nap time. He’s had a keen interest in bioethics since 2003.

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