Alongside benevolence, non-malevolence, and justice, the principle of autonomy is one of the four fundamental principles in medical ethics. Patient autonomy is defined as the patient’s right to make their own decisions (Timms, 2016). At that, the health worker’s role is to guide and educate them but not overtake the decision-making aspect of their treatment. The motivation for patient autonomy stems from the recognition of patients’ vulnerability in clinical settings. Indeed, such an environment is unusual for the majority of people. Due to negative emotions and the lack of expertise in the medical field, they can be swayed by medical paternalism and convinced to accept interventions without considering other options. However, as an ethical principle, autonomy has many nuances that need to be taken into account before translating this value into practice. This paper discusses how a nurse can maintain efficiency while respecting patient autonomy and what situations require prioritizing autonomy over the rest of the principles.
It is not unusual for nurses to work under time pressure, be it due to the necessity to deliver acute care or high workload that is not matched by an adequate number of employees. When work is fast-paced, it often becomes nigh-on impossible to pay attention to each patient and negotiate decisions from the place of respect for autonomy. For instance, the research by Vanderboom, Thackeray, and Rhudy (2015) demonstrated that as many as 64% of nurses did not have enough time to address patients’ fears and anxieties. In this case, there are opportunities for many ethical dilemmas that are likely to complicate the treatment process.
An example would be the workflow at an emergency department that is often chaotic and unstructured and leaves little to no time for negotiations. A patient brought to an emergency department after an injury may be administered a blood transfusion. While this intervention is likely to be helpful, the patient’s religious beliefs might condone such a practice. Still, the patient was not fully involved in the decision-making process because it was a life-or-death situation, and doctors and nurses prioritized his or her survivability above all.
Another example of an ethical dilemma arising from working in a fast-paced environment is the treatment of patients with mental impairments. Hess et al. (2015) describe a real-life case when an elderly woman with mild dementia was brought to an emergency department with a broken hip. Her daughter was chaperoning her, and it was the daughter who received the news that the best decision for her mother would be to have surgery (Hess et al., 2015). The daughter agreed with the offered option, and the emergency department proceeded with surgical intervention. The patient herself was excluded from the decision-making process while her daughter became a “surrogate decision-maker (Hess et al., 2015).” The time pressure must have put an extra strain on the department to reach out to the relative instead of trying to work through the challenges of mild dementia and communicate with the patient.
There must be a middle ground between patient autonomy and hospital efficiency. Hess et al. (2015) outline several approaches to creating an environment where medical ethics do not clash with performance. Firstly, there are organizational issues such as understaffing and poor scheduling that need to be tackled to promote ethical, patient-centered care. Secondly, changes must be made at the individual level: Vanderboom, Thackeray, and Rhudy (2015) show that 47% of nurses would like to receive additional training and mentorship. Continuing education would be a logical step toward accountability and ownership in medical staff.
Lastly, Hess et al. (2015) provide a tentative table of factors that could be guiding workplace policies with regard to patient autonomy. Researchers point out that there are both patient and provider factors that influence the way that decisions are made in fast-paced environments. According to Hess et al. (2015), with regard to patients, it is important to consider the acuity of illness, decision-making capacity, and desire to engage in the decision-making process. On the other hand, providers need to consider patterns of practice and defaults developed over time, medicolegal risk of decisions, and scientific evidence.
Sometimes the principle of autonomy has to be the guiding principle in nursing practice. For example, one can consider the following situation: an elderly woman is suffering from hypertension and final-stage renal failure. On one of the days, when she is brought to the hospital to receive hemodialysis, the nurses discover that her state is in a rapid decline: she is malnourished and has early signs of bedsores. After being evaluated by a social worker and a physical therapist, the patient is recommended to be placed in a skilled nursing facility. The recommendation is motivated by the woman’s inability to care for herself, which aggravates the effects of her pre-existing conditions.
However, the patient is adamant about staying home: she claims that she would rather die than lose her independence. The patient expresses her satisfaction with service at home and says that if no additional visits are possible, she will still be fine. When the woman is examined by a psychiatrist, he concludes that her cognitive faculties are intact; she is alert and capable of making decisions. Hence, her patient autonomy is not compromised by a mental disability.
The case above demonstrates a clash between two key medical ethics principles: autonomy and benevolence. On the one hand, if the patient stays at home, it increases her chances of recurrent complications and readmissions. On the other hand, health workers cannot dismiss her free will and desire to live independently until the end of her life. In this case, the principle of autonomy should prevail: doctors and nurses need to respect the patient’s values and allow her to uphold her dignity. The best decision would probably be to meet the woman where she is: accept her decision and attempt to make her lifestyle as safe and healthy as possible. For instance, it could be achieved by providing additional services at home. However, it should be noted that the present case does not imply any cognitive impairment, and if the latter was the case, medical staff would likely have more say in the final decision.
To conclude, patient autonomy is a complicated concept that does not easily translate into practice. Theoretically, the idea that patients need to be allowed to make decisions and choose from proposed options has both ethical and legal grounds. In practice, however, respect for patient autonomy is often compromised by the time pressure that many health workers experience in the workplace. Patient autonomy requires making individual and organizational changes such as training, continuing education, better human resource management, and transparent policies regarding decision-making.
References
Hess, E. P., Grudzen, C. R., Thomson, R., Raja, A. S., & Carpenter, C. R. (2015). Shared decision‐making in the emergency department: respecting patient autonomy when seconds count. Academic Emergency Medicine, 22(7), 856-864.
Timms, O. (2016). Biomedical Ethics-EBook. Elsevier Health Sciences.
Vanderboom, C. E., Thackeray, N. L., & Rhudy, L. M. (2015). Key factors in patient-centered care coordination in ambulatory care: Nurse care coordinators’ perspectives. Applied Nursing Research, 28(1), 18-24.