Are there any moral principles a health care professional should never violate?

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On a regular basis, healthcare professionals are confronted with ethical dilemmas in their practice. Hence, ethical problem solving requires the application of a variety of ethical rules and principles in specific situations[1]. Although ethical theories largely differ from one another, certain ethical principles appear consistently in the realm of bioethics. Thereby, respect for individual autonomy has quickly become a dominant principle in modern medical ethics.[2]

Autonomy in this essay shall be defined as individuals being independent and competent agents who are capable of making (a) rational and (b) unconstrained decisions. ‘Rational’ shall apply when an agent is able to ‘reason well’ and choose appropriate ends. ‘Unconstrained’ applies if all necessary elements for the individual to freely make an informed decision are present. Hence, individuals who fail to meet these criteria include patients in a comatose state, individuals suffering from forms of mental impairment or brain damage, and those in a drug induced state.

In this paper, the proposition that the principle of autonomy is the most fundamental principle in allowing patients to express their own free will shall be contended. Therefore, the purpose of this essay sets out to define the concept of autonomy and its importance. It is important to acknowledge that in some circumstances autonomy may need to be violated in order to protect individuals from exercising an irrational decision, particularly in cases where there are limited resources or other limiting factors which will comprise the final section of this essay.

 

Concept of Autonomy:

Autonomy has been defined as ‘at a minimum, self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding that prevent meaningful choice’.[3] In this regard, the principle of autonomy gives ultimate control for a moral action to the individual (or agent) in making a decision to perform an action according to his or her desires and values.[4] Autonomy of an individual can be violated through the use of manipulation, trickery, and deceit.[5] A physician who deliberately misguides their patient into believing they have cancer, in order to justify prescribing unnecessary chemotherapy and partake in expensive billing practices, is seen as a violation of patient autonomy.

Importance of Autonomy:

Autonomy recognizes the rights of individuals and their ability to self-determine what can be done in regards to their bodies. Kantian ethics have contributed to the notion of respecting patient autonomy and the related aspect of treating patients as ends in themselves.[6]  Kant’s central argument in his moral theory purports that ‘rational human wills are autonomous’.[7] Hence, choice is an expression of autonomy and what separates human beings from other beings rests on the idea of rationality.[8] In supporting Kant’s view on the principle of autonomy,  philosopher John Stuart Mill claimed  that the right to independence is absolute when it pertains to the individual and doesn’t infringe on the autonomy of others.[9]

Alan Gewrith argues that ‘rights are necessary for humans to be able to function as moral agents, displaying autonomy in the exercise of choice’[10], thus highlighting the need to defend autonomy as a right. The fundamental nature of autonomy was recognized as far back as 1914 when Cardozo J dictated in Schloendorff v New York Hospital: ‘every human being of adult years and sound mind has a right to determine what shall be done with his own body’.[11] This reasoning supports the idea that autonomous persons are likely to be in the best position to determine whether a decision would benefit them, hence why autonomy is of instrumental value in patient care.

Furthermore,  bioethicists such as Glover argue that patients should be permitted to make choices about their own treatment even if it is clear that ‘others would be in a better position to make choices that would serve the patients’ wellbeing’.[12] Glover argues that by giving up central decision making powers we ‘lose the sense of living our own lives’, and would rather ‘forgo a great deal of happiness, or risk a fair amount of disaster, to losing control of our lives in this way’.[13]  By removing patient autonomy, the patients’ dignity and independence is challenged.

 

 

Challenges to View of Autonomy:

 Autonomy is a principle of moral empowerment, where the responsibility for the consequences of an action are placed on moral agents themselves.[14] An individual that acts on this principle cannot legitimately blame another for the adverse consequences that occurred as a result of their decision. As stated by Mill, the perceptions of others are not a sufficient reason to warrant a stop to an individuals’ autonomous action. Mill argues that ‘person of individuality and character’ (now accepted as personal autonomy) can only flourish if protected from the ‘tyranny of the majority or society’.[15] In On liberty he argues that ‘power’ can only be exercised upon an individual if it prevents harm to others. Hence, an individual’s own good is not a sufficient reason to compel them ‘to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right’[16] In this view, Mill would oppose the act of paternalism on the grounds that it prevents individuals from developing independent character. Provided that a patient satisfies the rational and unconstrained criteria, the individual themselves should solely determine the value of their life. It would be unjustly paternalistic for another individual to interfere with the patients’ views on their life and impose treatment against their will.[17]

Discussion surrounding the principle of autonomy arises in the context of the ‘right of a patient to refuse life saving treatment’ and the balance for physicians to adhere to their beneficent duty.[18] Beauchamp and Childress recognize that in theory, physician obligations are to act for the patient’s medical benefit, and not to promote autonomous decision-making.[19]  Beneficence refers to the duty to do what is ‘believed’ to be in the patient’s best interests, such as cases where patients diagnosed with lung cancer want to continue to smoke. As such, the autonomous choice of the patient conflicts with the physicians’ duty to look out for the patient’s best interests. Following the path of beneficence or autonomy would lead the physician to take different actions. Personal autonomy, or self-determination, ‘requires a respect for the choice and wishes of people who possess decisional capacity, along with protecting those lacking capacity’. [20] Permitted the patient meets the criteria to make an autonomous decision, physicians should respect their wishes.

Self-determination was evidenced in Re C., in which an elderly man (C) suffering from paranoid schizophrenia developed gangrene in his foot and refused a life-saving amputation.[21] Although his general capacity to make decisions was impaired by schizophrenia, there was evidence that he understood and retained the relevant information and arrived at a clear choice. The reasons for respecting C’s wishes are two-fold. Firstly, non-consensual intervention where the individual is able to make a decision, regardless of the fact that they may not be able to make all decisions, violates their integrity. Secondly, unless there is reason to rebut their capacity,  competent persons are considered the best judges of their own welfare and interests. Only the individual can weigh the burdens, benefits, and harms of the proposed treatment in view of their wishes and values. If patients such as C refuse treatment on the basis that the treatment is not valued in their life then the refusal ought to be respected, regardless of the consequence of their decision.

Principally, competent patient’s decisions are generally respected in regards to healthcare. However, patient groups such as the elderly or young children often raise concerns about whether age or the onset of various physical and mental illnesses erodes the principle of autonomy. There is much debate over whether patients suffering from conditions such as “dementia”, or young children who are deemed competent, are truly able to make competent and rational decisions.[22]

The case of Makayla Sault, an 11-year old child suffering from acute lymphoblastic leukemia sparked debate into both the validity of indigenous medicine and the rights of children to pursue their own treatment[23]. Makayla was given a 75% chance of survival and in accordance underwent 11 weeks of chemotherapy and experiencing severe side effects. While in remission, Makayla wrote a letter to her medical team indicating that the chemo was killing her body, therefore electing to leave treatment and pursue alternative medicine.[24]  The courts decision to not intervene cited that she was not in need of protection because of her familial bond, as well as the use of traditional medicine which was within their right.[25] Listening to patients is crucial in promoting ethical health care, as well as respecting the patient’s right to determine choices for themselves, particularly in refusing treatment. By overriding Makayla’s decision, even if done in the name of her best interests, physicians would be disrespecting her personal autonomy, thereby amounting to an unjustifiably paternalistic attitude infringing on her personal integrity.

While the refusal of treatment is seen as an absolute right pertaining to adults, a ‘well considered refusal of treatment ought to be respected’ in the cases of young children, particularly if there is cultural relevance.[26] Opponents would question what is meant by a ‘well considered refusal of treatment’, and argue that refusing treatment would be deemed ‘ill-considered’ because it goes against medical advice. In this view, refusal of treatment should carry a greater ‘tariff’ then if a patient were to consent because of the fact it runs contrary to medical opinion. However, that argument is different from a refusal never being able to be ‘well-considered’, regardless if it’s contrary to medical opinion.[27]

True respect for autonomy hinges on the individual being autonomous, and therefore it would appear respectful of the principle to allow patients to refuse treatment, even if on irrational grounds. A key component of the principle of autonomy hinges on the fact that the patient is capable of making a specific decision pertaining to their care, as seen in Re C. Evidently, that does not mean that physicians cannot try to convince patients otherwise, as that would fail to acknowledge the premise of the duty to beneficence. As long as patients remain conscious of the consequences of their actions, respect for autonomy should outweigh the physicians’ duty to beneficence, particularly once the physician has exercised the presentation of all treatment options and their risks and benefits.[28]

Where patients are shown to lack capacity it can be argued that they are not autonomous and therefore the use of ‘best interests’ would apply. [29] Violating autonomy in the case of a patient suffering from a mental disorder being compulsorily confined and treated without their consent or a patient in a vegetative state is still consistent with the principle of autonomy because the act seeks to restore their autonomy and enable them to make decisions regarding their future care.[30] Hence, the best interests approach involves taking into account salient medical evidence, the patient’s wider personal interests, and  what the patient would have wanted before becoming incapacitous or currently wants (regardless of incompetence).[31] While this approach protects the self-determination of a patient, Bailey points out that ‘it is possible that decisions based on what somebody else views as the patient’s best interests will be made covertly under the guise of a substituted judgment’. [32]

                          Another concept to the challenge of autonomy surrounds the principle of the sanctity of life. With strong underpinnings in religion, the duty to respect life views human life as holy and inviolable.[33] This principle often appears in debates surrounding abortion and end of life decisions, in which physicians are to refrain from destroying life and instead seek to preserve it due to the belief that life holds intrinsic value. The thought of an individual being in a “incapacitous state” and subservient to other’s ‘best interests’ has been a particularly controversial issue, with many cases going before the courts to decide upon whether the ‘sanctity of life’ can violate the principle of patient autonomy.[34]  Preserving life is often seen as the highest duty of a physician, and those who support the practices of abortion and euthanasia are often confronted with arguments surrounding the sanctity of life.

According to the deontological school of thought, the sanctity of life approach emphasizes the need to protect life, where every individual has a right to life.[35]  This position can be attributed to the autonomy approach, in which a physician may be duty bound to respect the patient’s autonomous decision which may result in an earlier death. Having noted the discourse between the sanctity of life and autonomy, Hoffmann LJ in Bland observes the compatibility between these two concepts by pointing out that patients who refuse life-saving medical treatment are exercising their right to self-determination.[36] Allowing patients, in effect, to choose to die offends the principle of the sanctity of life.[37] Hence, a conflict between the two principles requires a painful compromise to be made and one having to be sacrificed. In this manner, a paternalist view would have autonomy denied in such an extreme case, and the principle of sanctity of life would be upheld.[38] Going down this route would have disturbing implications in clinical practice, particularly cases involving incompetent patients. To presume that the incompetent patient shall be subjected to treatment that a rational person would decline would ‘downgrade the status of the incompetent person’ and thereby lessen the value of his ‘intrinsic human worth and vitality’.[39] 

Problems with the View of Autonomy

While the principle of autonomy is an ideal worth protecting, it is evident that there are some justifications in violating for the principle.  While Mill set claimed  the non-interference of people’s actions and decisions as a necessary condition to autonomy, it is apparent that this rationale is not a sufficient condition.[40] In this respect, a homeless individual who requests to have his leg amputated because it would benefit his prospects on the street should have his autonomy violated. There is an inherent flaw if applying these straightforward claims about autonomy, in that as long as the decision was rational and unconstrained, then this individual should have his request honored. It is apparent that the right to autonomy does not entitle patients to request or demand all treatment, such as amputation of a healthy limb. As fundamental as autonomy is there must be some limits , as supported by Kant, who believed that autonomy is tied to our rational nature.[41] According to Kant:

‘There are compelling independent ethical arguments to suggest that the exercise of full autonomy requires some element of rationality … not [a] mere choice but an evaluative choice of which of the available courses of actions is better or best.’[42]

Kant’s view acknowledges that an autonomous decision cannot merely be a wish, but a decision that takes into account rational consideration and appropriate information. Savulescu argues that the decision should not be dependent on whether it is or is not prudent, but whether the imprudent decision was made on a rational or irrational basis.  As Savulescu explains, ‘rational imprudence is imprudence based on a proper and rational appreciation of all the relevant information and reasonable normative deliberation.’[43] This rationality explains why it is permissible to respect someone’s autonomy in cases where a patient with strong religious convictions, such as a Jehovah’s Witness, refuses a life-saving treatment. In this case while the decision itself can be considered imprudent, it becomes rational when religion is considered because their beliefs over spiritual well-being takes precedence over life itself. Irrational imprudence occurs when ‘there are no good overall reasons’ to engage in such act, as the individual ‘is not thinking clearly about information at hand or holds mistaken values or wildly inaccurate estimates of risk’.[44] Where a patient requests to remove his healthy limb, violation of autonomy can be acceptable because their request serves no medical purpose. The physician’s appropriate response should be to dissuade the patient from pursuing their irrationally imprudent decision because such desire is not autonomous and would produce more harm than benefit. Exercising a completely autonomous choice centers on the fact that the decision being rational, but realistically autonomous decisions ‘often turn on the reasons an individual has in a particular situation’.[45] Controversially, Bayne and Levy use the healthy limb example arguing that the request for amputation of a limb may represent Body Integrity Identity Disorder, a poorly understudied condition. Individuals are often driven to dangerously remove limbs themselves as alternative treatments are generally ineffective.[46]. Surgeons would be permitted to remove their healthy limb provided alternative options have been exercised.[47] Normative deliberation in cases of health limb removal is not sufficient in itself to make the action rationally defensible in all cases.

Conclusion:

Respect for autonomy as a principle of bioethics assumes a certain level of respect for persons and their corresponding ability to make decisions that affect their health and wellbeing. As pointed out earlier in this essay, personal autonomy is synonymous with the right of self-determination, and hence has become one of the foremost and fundamental guiding principles in allowing individuals to express their own free will. It is evident that while both autonomy and beneficence are to be practiced by health care professionals, in most cases autonomy will outweigh the latter so long as the patient is able to make a rational and unconstrained decision, regardless of the fact that the treatment would run against the patient’s best interests.

Whether someone should live or die is generally not a decision that can be decided upon without an objectionable denial of the competent individual’s autonomy. However, that does not mean that healthcare professionals are obligated to honor all requests, particularly if the patient fails to understand the nature, purpose, and proposed effects of their medical treatment. Arguably, removing a healthy limb may be permissible if all the less invasive treatments have been exhausted and if the final procedure produces greater benefit than harm. Hence, in rare situations this may be the desirable option. As such, the principle of autonomy should not be violated in cases where the request or decision is rational, but limits should be applied in cases where the decision is imprudent and irrational, as that is not what autonomy demands.

 

 

 

 

Works Cited

 

Airedale N.H.S. Trust v Bland [1993] 2 WLR (HL).

 

Almond, B. (1993) ‘Rights’, in Peter Singer (ed), A Companion to Ethics, Blackwell 1993)

 

Piper, M., ‘Autonomy: Normative’ (James Madison University, n.d.)

< http://www.iep.utm.edu/aut-norm/> accessed 2 December 2015

 

Bayne, T. & Levy, N. (2005) Amputees by choice: body integrity disorder and the ethics of amputation, Journal of Applied Philosophy, 22(1): 75-86

 

Brennan, T. ‘Ethics of Disclosure Following a Medical Injury’, in Rosamond Rhodes, Leslie Francis & Anita Silver (edn), The Blackwell Guide to Medical Ethics (Blackwell 2007)

 

Beauchamp, T. & Childress, J., Principles of Biomedical Ethics (6th edition, OUP 2008)

 

Davies, E., ‘Is old age an ethical problem?’ (GM, 2013)

<https://www.gmjournal.co.uk/Is_old_age_an_ethical_problem_86237.aspx> accessed 29 November 2015

 

Donna Dickenson, D., Huxtable,R. & Parker, M., The Cambridge Medical Ethics Workbook (2nd edition, CUP 2010)

 

Foster, C. (2011) ‘Human Dignity in Bioethics and Law’, Bloomsbury

 

‘Geriatrics: Decision-Making, Autonomy, Valid Consent and Guardianship’ (University of Miami, n.d.) <http://www.miami.edu/index.php/ethics/projects/geriatrics_and_ethics/decision-making_autonomy_valid_consent_and_guardianship/> accessed 15 November 2015

 

Gillon, R., ‘The Sanctity of Life Law Has Gone Too Far’ (Gresham College, 2014) <http://www.gresham.ac.uk/lectures-and-events/the-sanctity-of-life-law-has-gone-too-far>

 

Glover, J. (1977) ‘Causing Death and Saving Lives’, Penguin.

 

Hamilton Health Sciences Corp. v. D.H., 2014 ONCJ 603.

 

Harris, J., (1985), The Value of Life, New York: Routledge and Kegan Paul

 

Kant’s Moral Philosopy’ (Stanford Encyclopedia of Philosophy 2008) <http://plato.stanford.edu/entries/kant-moral/#Aut> accessed 10 November 2015

 

Michel, J.P., ‘When the Sanctity of Life Includes the Right to Choose Death’ (The Gospel Coalition, 2015) < http://www.thegospelcoalition.org/article/when-sanctity-of-life-includes-the-right-to-choose-death> accessed 15 November 2015

 

Mill, J.S., On Liberty, in John Gray (ed), John Stuart Mill: On Liberty and Other Essays (OUP 1991)

 

Pantilat, S., ‘Autonomy vs. Beneficence’ (University of California, 2008) <http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_auton_bene.htm>

 

Re C (Adult: Refusal of Treatment) [1994] 1 WLR 290 (FD)

 

Savulescu, J, ‘Autonomy, the good life and Controversial Choices’, in Rosamond Rhodes, Leslie Francis & Anita Silver (edn), The Blackwell Guide to Medical Ethics (Blackwell 2007) 27

 

Schloendorff v New York Hospital [1914] 105 N.E. 92 (CA)

 

Suber, P., ‘Against the Sanctity of Life’ (Earlham College, 1985)

< http://legacy.earlham.edu/~peters/writing/sanctity.htm> accessed on 2 December 2015

 

Superintendent of Belchertown State School v Saikewicz [1977] 370 N.E. 2d. 417, 428

 

Ulrich, L., ‘Ethical Principles in Healthcare Ethics’ (University of Daytona, n.d) <http://academic.udayton.edu/lawrenceulrich/315prinsme.htm> accessed 12 November 2015

 

Varelius, J, ‘The value of autonomy in medical ethics’ (2006) 9(3) MHCP <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780686/> accessed 12 November 2015

 

Vevaina, JR, Nora, LM & Bone, RC, ‘Issues in Biomedical Ethics’, (1993) 39(12) DM <http://www.ncbi.nlm.nih.gov/pubmed/824322> accessed 10 November 2015

 

Walker, C., ‘Makayla Sault, girl who refused chemo for leukemia, dies’ CBC News, (January 19, 2015) <http://www.cbc.ca/news/aboriginal/makayla-sault-girl-who-refused-chemo-for-leukemia-dies-1.2829885> accessed 10 November 2015

 

Walker, C., ‘Makayla Sault will not be apprehended by Children’s Aid’ CBC News, (May 20, 2014) < http://www.cbc.ca/news/aboriginal/makayla-sault-will-not-be-apprehended-by-children-s-aid-1.2648562> accessed 10 November 2015

 

Walsh, P. Autonomy- Handout (King’s College London, 2015)

 

 

[1] JR Vevaina, LM Nora & RC Bone, ‘Issues in Biomedical Ethics’, (1993) 39(12) DM <http://www.ncbi.nlm.nih.gov/pubmed/824322> accessed 10 November 2015

[2] Elizabeth Davies, ‘Is old age an ethical problem?’ (GM, 2013)

<https://www.gmjournal.co.uk/Is_old_age_an_ethical_problem_86237.aspx> accessed 29 November 2015

[3]Tom Beauchamp & Jeff Childress, Principles of Biomedical Ethics (6th edition, OUP 2008) 58

[4] Lawrence Ulrich ‘Ethical Principles in Healthcare Ethics’ (University of Daytona, n.d) <http://academic.udayton.edu/lawrenceulrich/315prinsme.htm> accessed 12 November 2015

[5] ibid.

[6] Troyen Brennan, ‘Ethics of Disclosure Following a Medical Injury’, in Rosamond Rhodes, Leslie Francis & Anita Silver (edn), The Blackwell Guide to Medical Ethics (Blackwell 2007) 394

[7]‘ Kant’s Moral Philosopy’ (Stanford Encyclopedia of Philosophy 2008) <http://plato.stanford.edu/entries/kant-moral/#Aut> accessed 10 November 2015

[8] Julian Savulescu, ‘Autonomy, the good life and Controversial Choices’, in Rosamond Rhodes, Leslie Francis & Anita Silver (ed), The Blackwell Guide to Medical Ethics (Blackwell 2007) 27

[9] J.S. Mill, On Liberty, in John Gray (ed), John Stuart Mill: On Liberty and Other Essays (OUP 1991).

[10] Brenda Almond, ‘Rights’, in Peter Singer (ed), A Companion to Ethics (Blackwell 1993)

[11] [1914] 105 N.E. 92 (CA)

[12] Jukka Varelius, ‘The value of autonomy in medical ethics’ (2006) 9(3) MHCP <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780686/> accessed 12 November 2015

[13] Jonathan Glover, ‘Causing Death and Saving Lives’ (Penguin, 1977) 81.

[14] Ulrich ibid (n 4)

[15] Mill ibid (n 9)

[16] ibid.

[17] Donna Dickenson, Richard Huxtable, & Michael Parker, The Cambridge Medical Ethics Workbook (2nd edition, CUP 2010) 3

[18] Steve Pantilat, ‘Autonomy vs. Beneficence’ (University of California, 2008) <http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_auton_bene.htm>

[19] Beauchamp ibid (n 3) 272

[20] Davies (n 2)

[21] Re C (Adult: Refusal of Treatment) [1994] 1 WLR 290 (FD)

[22] ‘Geriatrics: Decision-Making, Autonomy, Valid Consent and Guardianship’ (University of Miami, n.d.) <http://www.miami.edu/index.php/ethics/projects/geriatrics_and_ethics/decision-making_autonomy_valid_consent_and_guardianship/> accessed 15 November 2015

[23] Connie Walker, ‘Makayla Sault, girl who refused chemo for leukemia, dies’ CBC News, (January 19, 2015) <http://www.cbc.ca/news/aboriginal/makayla-sault-girl-who-refused-chemo-for-leukemia-dies-1.2829885> accessed 10 November 2015

[24] Case precedence in J.J: Hamilton Health Sciences Corp. v. D.H., 2014 ONCJ 603

[25] Connie Walker, ‘Makayla Sault will not be apprehended by Children’s Aid’ CBC News, (May 20, 2014) < http://www.cbc.ca/news/aboriginal/makayla-sault-will-not-be-apprehended-by-children-s-aid-1.2648562> accessed 10 November 2015

[26] Dickenson (n 17) 11.

[27] ibid.

[28] Steve Pantilat, ‘Autonomy vs. Beneficence’ (University of California, 2008) <http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_auton_bene.htm>

[29] M Stauch & K Wheat, ‘Text, Cases, and Material on Medical Law and Ethics’,  (Routledge 2015) 31

[30] ibid 33.

[31] Dickenson (n 17) 8.

[32] ibid 16.

[33] Raanan Gillon, ‘The Sanctity of Life Law Has Gone Too Far’ (Gresham College, 2014) < http://www.gresham.ac.uk/lectures-and-events/the-sanctity-of-life-law-has-gone-too-far>

[34] ibid.

[35] Dickenson (n 17) 8.

[36] Airedale N.H.S. Trust v Bland [1993] 2 WLR (HL)

[37] ibid 351.

[38] Bland (n 36) 352.

[39] Superintendent of Belchertown State School v Saikewicz [1977] 370 N.E. 2d. 417, 428

[40] Pat Walsh, Autonomy- Handout (King’s College London, 2015)

[41] Savulescu (n 8) 28

[42] J., Harris (1985), The Value of Life, New York: Routledge and Kegan Paul

[43] Savulescu (n 41) 27

[44] ibid.

[45] Savulescu (n 8) 28

[46] Bayne, T. & Levy, N. (2005) Amputees by choice: body integrity disorder and the ethics of amputation, Journal of Applied Philosophy, 22(1): 75-86

[47] ibid.