Principle of Respect for Autonomy

by Mark Hughes, MD, MA

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    00:01 Let's first of all think about respect for autonomy.

    00:05 So this goes back to the philosophical notion that you have reasoning, you have reasoning ability, you're a rational agent, and a patient is going to be capable of making their own decisions.

    00:15 You as the clinician, you know, you're also capable of making your own decisions and how you're going to perform your actions.

    00:22 But when we're thinking about respect for autonomy, it's usually thought about in terms of the patient's autonomy.

    00:26 And we want to respect their autonomy.

    00:30 The first idea is that, you know, being able to choose your own decisions, you know, that's an idea of self-rule or self-determination.

    00:38 How do we want to govern ourselves in our world and make sure that we're being true to ourselves? There is this notion of liberty rights.

    00:47 So not making sure the people are interfering with your liberty, your ability to have freedom of will, make your own choices.

    00:55 That's another element of respect for autonomy.

    00:59 It also means that you don't want other people to control your actions, so being free of controlling interference by others.

    01:07 So each person can, you know, you can swing your fist in the air, but once it hits another person you are not respecting that other person's autonomy.

    01:17 So being free of controlling interference by others.

    01:21 And then lastly and especially in medicine, we have to have freedom from limitations such as inadequate information.

    01:28 So one of the roles of the physician in terms of doing informed consent, that we'll hear about in a future lecture, is this idea of giving them enough information so they can make decisions, so they can be self-ruling.

    01:44 Now, there are going to be some limits on the principle of respect for autonomy.

    01:48 So we're always thinking about in terms of rationality and a person being able to reason themselves through getting information and making decisions.

    01:58 But in illness, people are vulnerable and there may be times when some choices are non-rational.

    02:04 Doesn't mean that they're irrational, but they just are not on the realm of being on, you know, reasoning.

    02:10 This idea of, you know, making a decision out of love. Is that a rational reason? No, you're making it on behalf of let's say a family member.

    02:20 A patient that is, you know, has advanced cancer and they have to make a decision whether to go through another round of chemotherapy.

    02:29 They themselves may say "No, I don't wanna go through this again." But their loved ones really want them to try to continue to fight the illness.

    02:39 There that choice is non-rational, it's not being reasoning through the risks and the benefits, but it's out of love for their family member.

    02:49 Another concern with the principle of respect for autonomy is this issue of authenticity, which we'll hear about in a future lecture in terms of advanced care planning.

    02:57 So the decisions I make today, how relevant are they going to be in my future self? You know, is there an issue of am I making authentic choices now that are gonna be the same when I perhaps, you know, have your serious illness that I have to confront.

    03:17 Next, there is going to be this way of which choices are purely self-regarding, none of us live in isolation.

    03:25 None of us are automatons that, you know, just think about ourselves.

    03:29 We generally have a sphere of others in our lives that we are also thinking about.

    03:34 So sometimes our decisions are not purely self-regarding, but are also taking into account our loved ones or acquaintances or friends and so on.

    03:45 There may also be times when autonomy has jurisdictional limits and we certainly saw that in the pandemic where people may make autonomous choices of, you know, deciding for themselves or whether or not they want to wear a mask.

    03:58 But there might be needs for public health of restricting a person's autonomy and there may be ways that the law influences where the person can truly make autonomous choices.

    04:11 And that also then leads to this idea of the collective body, you know, so there might be elements of thinking about the larger society and its interest in making choices and sometimes limiting a person's autonomy in the interest of the larger community.

    04:30 And there's also this question of when we say okay you live your life.

    04:35 Is that idea of non-interference really facilitating or hindering autonomous choices? If you know a person is going into a very risky situation and you want to warn them against it, do you just say, you know, do what you want. Or do you actually pause and say "You know I respect you enough, I wanna make sure you're able to make future decisions.

    04:59 I think I need to warn you about going into this risky situation." So, a lot of us think about, you know, respect for autonomy and the autonomous choices that patients may make.

    05:12 But I also think it's important to think about respect in terms of respecting the person.

    05:17 Respecting the idea that each person has an inherent dignity that is not just based on their reasoning ability, but that just being a person they are owed respect.

    05:31 And that is that they have unconditional value that this person is important just for being a person, just for their humanity and we should recognize that and respect that.

    05:44 It also means that respect should be applied to everyone.

    05:47 This idea then, you know, gets us into thoughts about justice.

    05:52 So, applying respect to everyone we encounter.

    05:55 Not favouring one patient over another but respecting all patients.

    06:01 And then lastly, it's not just how we act towards a person, how do we show them respect, but do we actually believe, you know, is it a core value for us that respect should be owed to everyone? So both in our actions and in our beliefs and our thoughts we are going to demonstrate that respect.

    06:24 And then, it's not just the individual patient, but also respecting that patient comes from a culture and all of us have different attributes, different cultures that we, you know, all combine into to be who we are.

    06:39 And culture basically is the idea of shared meanings, values, rituals, ways of interacting.

    06:47 You know everything that comes in to being in ones culture and that idea, that combination of things then influences how people understand and make sense of the world.

    07:00 So, we think about, you know, how you've been raised, the family is one place where you learn your culture.

    07:08 You, maybe, have cultural traditions.

    07:10 That when you then go into, you know, the healthcare arena, you're a patient that's sick you bring your culture with you.

    07:18 And the clinicians are going to have to respect your cultural attributes and know how best to serve you based on your cultural understandings.

    07:29 It may influence how the patient interprets their symptoms.

    07:33 So, how did they make sense of what they're feeling physically or emotionally? Is that part of, you know, what the culture says about having a disease? It may influence how they cope with their symptoms.

    07:47 If they're sick, you know, are there different rituals that cultures might adhere to in terms of the sick role and how other people need to take care of them.

    07:59 It may influence a person's ability to even seek healthcare.

    08:03 You know, what is their approach to health? Are they thinking about physical fitness as a, you know, core element of their culture? Do they sort of neglect their health and think about other things that are more important based on their cultural underpinnings? That can then influence how they then approach, you know, the healthcare setting and thinking about care planning.

    08:28 You may have heard of, you know, patients that are reluctant to go see the doctor and only with the encouragement of a significant other do they actually seek medical care.

    08:37 That might be based on cultural underpinnings.

    08:42 It also may influence the choice of treatment.

    08:44 So, are things more or less acceptable to one's culture? A classic example would be the Jehovah's Witness religious tradition would say they would not want a blood transfusion.

    08:58 So does that cultural underpinning influence their choice of treatment whether they would accept or decline a blood transfusion if they have anemia? And also the culture may speak to their adherence to treatment.

    09:12 So, how accustomed are they to taking pills and following the doctor's orders as it were? How are they going to adhere to the treatment or might they be in a place where they decide not to seek treatment or adhere to what's being suggested for them?

    About the Lecture

    The lecture Principle of Respect for Autonomy by Mark Hughes, MD, MA is from the course Introduction to Clinical Ethics.

    Included Quiz Questions

    1. ...the patient.
    2. ...the clinician.
    3. ...the staff.
    4. ...the parents.
    5. ...the siblings.
    1. Placing unconditional value on every person
    2. Giving people space when needed
    3. Remembering a coworker's birthday
    4. Providing emotional support to a stranger
    5. Giving gifts to a loved one during the holiday season
    1. Individual personal memories
    2. Shared values
    3. Shared meanings
    4. Shared rituals
    5. Shared modes of interaction
    1. Pathology of Alzheimer disease
    2. Interpretation of symptoms
    3. Coping strategies
    4. Approach to health
    5. Level of engagement in care planning
    1. Respecting the decisions of those who have decision-making capacity
    2. Respecting the decisions of adults
    3. Respecting the thoughts of adults
    4. Respecting the thoughts of children
    5. Respecting the autonomy of people you know

    Author of lecture Principle of Respect for Autonomy

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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