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Recognizing Violations of Patient Autonomy

Case Presentation

 

Cora is a 45-year-old woman who looks years older than her stated age. She has very limited monthly income and no health insurance. Cora smokes two and one-half packs of cigarettes per day. She has severe COPD with constant dyspnea and frequent exacerbations. The nurse who sees her at a local free clinic is interested in at least preventing further problems, and speaks to Cora often about the importance of quitting smoking. The situation becomes very frustrating for all involved when Cora returns repeatedly for increasingly severe problems, having failed to quit smoking. Cora, of course, becomes labeled as noncompliant. During a particularly severe exacerbation, the nurse says to Cora, “You know you are committing suicide by continuing to smoke.” Cora’s reply is, “You don’t understand. I live alone. I have no money, no friends, no family, and will never be able to work. I know the damage I’m doing, but smoking is the only pleasure I have in life.”

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Think About It

Do Nurses Coerce Patients?

· In attempting to persuade Cora to stop smoking, to what degree is the nurse violating Cora’s right to autonomy?

· Does Cora have the right to choose to continue smoking?

· If rights and responsibilities are correlative, how should the clinic respond to Cora’s continuing to smoke? Would you suggest that the clinic continue to serve Cora, even though she is not following the plan of care?

· To what degree is coercion employed in situations such as Cora’s ? Is coercion an appropriate strategy?

 

RESPECT FOR AUTONOMY

As you would expect, the ethical principle of respect for autonomy denotes the ethical obligation to honor the autonomy of other persons. The word autonomy literally means self-governing. Autonomy denotes having the freedom to make choices about issues that affect one’s life, free from lies, restraint, or coercion. Respect for autonomy is closely linked to the notion of respect for persons, and is an important principle in cultures where all individuals are considered unique and valuable members of society.

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FIGURE 3–1 Principles of Ethics

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Implied in the concept of autonomy are four basic elements. First, the autonomous person is respected. It is logical that those choosing the nursing profession would inherently value and respect the unique humanness of others. This element is essential to assuring autonomy. Second, the autonomous person must be able to determine personal goals. These goals may be explicit and of a global nature, or may be less well defined. For example, the patient with an ankle injury may have a goal to return to athletic play within 2 weeks of the injury, or may simply wish to be pain free. In either case the patient develops personally chosen goals that are consistent with a particular lifestyle. Third, the autonomous person has the capacity to decide on a plan of action. The person must be able to understand the meaning of the choice to be made and also deliberate on the various options, while understanding the implications of possible outcomes. Imagine, for example, ordering from a restaurant menu written in a language you do not understand. You have the freedom and responsibility to make a choice, but cannot make a meaningful choice without an understanding of the various foods offered. When we believe that a patient is not able to comprehend the meaning of choices, goals, or outcomes, we say that the person is incompetent to make decisions, or lacks decision-making capacity. There are certain groups of patients that are generally thought of as unable to make informed choices. Children, fetuses, and those with mental impairments are among these groups. Fourth, the autonomous person has the freedom to act upon the choices. In situations where persons are capable of formulating goals, understanding various options, and making decisions, yet are not free to implement their plans, autonomy is either limited or absent. Autonomy may also be limited in situations where the means to accomplish autonomously devised plans do not exist. An example is seen in the case of the indigent person who has no health care insurance. This person may choose to have, for example, a pancreas transplant in lieu of insulin injections, but has no financial means to meet this goal. In order to assure autonomy, each of the four elements must be present to a reasonable degree.

A number of factors may threaten patient autonomy. The patient’s role is a dependent one. The patient seeks health care assistance because of a real or perceived need and, as a result, can be perceived as dependent upon the health care provider. The role of the health care professional, on the other hand, is one of power. This power is based upon knowledge and authority and is inherent in the role. This complementary relationship, while a necessary one, can lead to violations of patient autonomy because the patient may not have the strength of will to exert his or her own autonomy.

ASK YOURSELF

Is the Patient Role a Dependent One?

· Describe a time when you or a family member experienced the role of hospitalized patient.

· How did you or your family member feel when interacting with members of the health care team, who were dressed, while you or your family member were in pajamas or a hospital gown or, worse yet, naked?

· Describe the degree to which you or your family member were able to maintain dignity and autonomy.

 

Health care professionals are often insensitive to the ways in which the health care industry systematically dehumanizes and erodes the autonomy of consumers. Patients are forced to comply with rules that require them to be and act dependent. Immediately upon admission to a hospital, patients are disrobed, asked questions about personal and private matters, forced to relinquish money and belongings, and expected to remain in a bed, emphasizing the dependency of the patient role. We place patients in rooms with doors that are seldom closed and ask them to wear bed clothing. Workers who are strangers to patients freely enter and leave the patients’ rooms, making privacy impossible. Regardless of patients’ personal habits or knowledge of their own health care, they are forced to bathe at certain times, eat at certain times, and take medications at certain times, and are often prohibited from practicing self-care measures that may have been their habits for many years. Patients are expected to follow each plan that is made. Otherwise, they will be labeled difficult or noncompliant. For all the lip service given the importance of autonomy, health care professionals are often guilty of creating a climate of dependency for patients—of coercing otherwise autonomous, intelligent, and independent adults into essentially a very dependent role.

In cultures that do not regard all people as being of equal worth and in cultures that respect social structure above individual rights, autonomy is less important. Where slavery exists, where women are expected to be subservient to men, where minority races are not respected, or where children are exploited, the notion of autonomy is meaningless. Autonomy cannot thrive in a climate that does not allow for either the independent planning of personal goals or the privilege of examining and choosing options to meet goals.

Recognizing Violations of Patient Autonomy

Often, nurses and other health care workers fail to recognize subtle violations of patient autonomy. This especially occurs when nurses perceive choices to be self-evident. At least four factors are related to this failure. First, nurses may falsely assume that patients have the same values and goals as themselves. This state of mind compels some nurses to believe that the only reasonable course of action is the one that is consistent with their own values. This leads to faulty conclusions. For example, if an elderly person chooses to stay in her own home, even though to others she seems incapable of caring for herself, her choice might be viewed as unreasonable and might become grounds to believe the patient is incompetent to make decisions. In other words, “If you don’t make the choices that seem correct to me, you must be incompetent to make decisions.” In truth, the elderly person may recognize that life is drawing to a close and may want to remain in familiar surroundings, maintain dignity, remain independent, and prevent needless depletion of her life savings. The decision is based upon her thoughtful consideration of the consequences of staying home versus the consequences of living in a long-term care facility. There are some who would insist that she should be allowed to stay at home, even if she places herself at considerable danger, as long as she does not jeopardize the autonomy of others.

The second cause of failure to recognize subtle violations of patient autonomy lies in our failure to recognize that individuals’ thought processes are different. Discounting a particular decision as incorrect may not take into consideration the fact that people process information in different ways. For example, there are those whose thought processes are very logical and methodical, and there are others who think in ways that are creative and free-flowing. It is particularly important to recognize these types of differences when several people are working together to come to a common decision. What is obvious to one will not be obvious to all—not necessarily because of a difference in values, knowledge base, or intellect, but because of different backgrounds and styles of thinking (Harrison & Bramson, 1982). This is an important consideration when collaborating with patients, families, and other professionals.

The third cause of failure to recognize subtle violations of patient autonomy lies in our assumptions about patients’ knowledge bases. It is easy for us to forget that we have gained a specialized body of knowledge through nursing education and work experience. Knowledge about basic anatomy and physiology, disease process, the mechanism of action of drugs, and so forth is so ingrained in our minds that it is easy to presume everyone has at least some of the same type of knowledge. We often assume patients have more knowledge than is reasonable for them to have. Consequently, we may discount or criticize patients’ decisions, even though flaws lie in the patients’ level of knowledge, rather than the appropriateness of decisions. Recall that an understanding of the choices, outcomes, and implications is inherently necessary for autonomous decision making. The nurse must accurately assess the patient’s level of understanding in order to assure autonomy.

Most people accept the concept of autonomy, but few are prepared to accept total autonomy for every person in every situation. The ethical principle of respect for autonomy does not require you to respect all autonomous actions no matter how irrational the decision or horrible the results might be. Although you value the principle of respect for autonomy, you must simultaneously uphold responsibilities to yourself and to other people who could be harmed by a patient’s choices. This can be a difficult distinction to make. To the extent that it is unreasonable accept the autonomous decisions and actions of all people in all circumstances, we are called to respect the principle of autonomy, rather than each autonomous action (Gillon, 1985).

The fourth cause of our failure to recognize subtle violations of patient autonomy lies in the unfortunate fact that in some instances the “work” of nursing becomes the major focus. This produces a climate of industrious habit. As we go about our work—doing procedures, giving medications, writing care plans, and trying to keep up a frantic pace—attentiveness to patient autonomy is sometimes neglected. In today’s climate of advanced technology, fiscal uncertainty, staffing reductions, and bottom-line management, we should guard against focusing on work rather than caring.

 

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