Medical School Interviews Medical Ethics: Autonomy
When facing ethical dilemmas doctors should consider the patients autonomy. Alongside beneficence, justice and non-maleficence; autonomy is one of the 4 pillars of ethics.
Respect for autonomy means to respect the ability of a patient to make their own decisions, this means patients have the ability to “self-rule” and make decisions about their lives. When patients practice their autonomy, they are remaining involved in their healthcare. When patients engage in their healthcare there is increased patient satisfaction and better clinical outcomes.
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Autonomy in modern medicine
Autonomy is a relatively new principle and idea in medicine. In the past therapeutic relationships between doctors and patients were based upon paternalism. Paternalism is practiced when decisions are taken by the doctor only, reducing patient engagement in the decision-making process. Modern practice has adapted to ensure that the wants, needs and requirements of patients are respected. Decision making is now a collaborative process between the doctor and patient. An autonomous patient can request or refuse treatments and investigations. However, patients cannot demand a treatment and doctors must ensure that even when promoting autonomy their practice aligns with guidelines set out by the GMC and governing bodies such as NICE.
Ethical scenario questions
Many MMI stations involve talking to others in vulnerable positions in a role of responsibility or as a friend. You may have to discuss how to approach someone who has done something unethical. Good answers show an awareness of how you can give the individual autonomy by asking them how they would like to proceed with the issue and facilitating them to put their choices into action.
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We can show respect for a patient’s autonomy by gaining consent. This is fundamental to good medical practice and allowing patients to be autonomous. Patients must consent to any form of medical treatment, test or examination. This may be verbal or in writing. In order for individuals to make autonomous decisions they must provide consent based on a validity criteria. Valid consent must be voluntary, informed and the person consenting must have capacity.
- Informed – In order for patients to make an informed decision about their care they must have adequate information to base their decision upon. Doctors should provide information to patients ensuring they tell the patient what a reasonable or this particular patient would want to know. This doesn’t only involve information about the material risk of the treatment itself but information about their problem they have and its implications. What will the consequences be if they refuse treatment and what implications could this have on others? The Ask 3 questions initiative was launched by the NHS to allow patients to be reassured that they have adequate information to engage in shared decision making. Doctors should answer the following questions: What are the patients’ choices? What are the pros and cons of each choice? And how does the patient get support to make an informed decision?
- Capacity – a patient must have capacity to make decisions meaning they must be able to use, retain, communicate and understand information provided. Patients are assumed to have capacity to make decisions and consent to treatment unless there are reasons to think otherwise such as an impairment of, or disturbance in the functioning of the mind and brain. A patient’s capacity and the treatment of an incapacitated patient is governed by the Mental Capacity Act 2005.
- Voluntary – consent is only valid where it is voluntary. The patient should consent without force, coercion or fraud.
If doctors fail to respect their patients’ autonomy, and harm is caused where consent isn’t provided, there can be serious detriment. Legally doctors who fail to provide all the necessary information to a patient can be charged for negligence. It is deemed more serious where harm is done to the patient where consent gained.
The principle of respect for autonomy underpins the requirement that doctors keep patient information confidential. Patients should have control over information about themselves. It is a privilege as a doctor to be trusted with your patient’s private information, and maintaining confidence is an intrinsic part of the process of developing trustful doctor-patient relationships. Doctors and medical students must ensure they are confident with what information they can and cannot share with family and other parties involved in the patient’s treatment.
Examples of confidentiality scenarios questions:
- Witnessing friends/ consultants breaching confidentiality – Good answers would identify the issue that confidentiality has been breached, explaining how this breach has occurred e.g. what information has been disclosed and who to? Explore the impact of breaching confidentiality and cite the GMC guidelines on the topic. When describing your planned actions don’t only state what you would do but how you would do it and what skills you would utilise.
- Consider the environment you would conduct the conversation in
- Be non-judgmental. This can be achieved through non- verbal communication skills such as open body language and verbal communication skills such as using open questions and active listening whilst avoiding being patronising and aggressive.
- Family members/ other parties requesting information to be disclosed? – consider which instances you can disclose information. For example, information can be disclosed to the multidisciplinary team, for referrals, where the patient is not competent and if the patient’s condition put them at risk of harm. Consider how you would disclose information ensuring that you explain to the patient what will be disclosed. Disclose minimal information and protect information when it is disclosed (ensure an appropriate environment)