ICTPH Ethics Series Part II – Autonomy

Autonomy literally refers to freedom from external control or influence, or simply “independence”.

Autonomy plays a crucial role in medical ethics. The relationship between the health system and the patient is based on mutual trust and mutual interest, given that both the parties are independent to make their decisions based on the information available.

When care seeker enters the medical facility for seeking care, he/she has entered the facility with his own will and he/she has all the rights to walk out from the facility at any given time without any questions asked by the health care provider. The job of the health care provider is to present before the care seeker with all the possible treatment, diagnostic modalities while the care seeker has all the freedom about selection of the treatment or diagnostic tests, care seeker is also free to deny all the treatment if he/she thinks the provided options are not in his/her best interest. While care provider can only present the pros and cons of the treatment options and share his views on each of them but the ultimate decision of the care seeker should be considered final.(1) This is the theoretical definition of autonomy but when it comes to real life scenario pin point application of the theory is extremely difficult.

While dealing with real life scenarios, autonomy should be viewed from two lenses of “Informed Consent” and “Equipoise”(2)

Informed Consent

Informed consent is the most important aspect of respecting the autonomy of the care seeker. Informed consent is and legal document which symbolizes the agreement between the care provider and care seeker, wherein a care provided as provided the care seeker suitable information and time to take and informed decision.(3) In simpler words informed consent is the document that states both the parties are in agreement ethically and legally.

How does informed consent helps to protect the autonomy of the care seeker?

A 30 year old male patient walked in a primary care clinic with a chief complaint of watery stools and pain in upper left side of abdomen, form past 2 days, the patient was in conscious, well oriented, and febrile. The clinician after thorough clinical examination and history taking the abdomen was tender and no symptoms of fever or vomiting, suspected the case of acute gastritis and prescribed the medication for the same for 3 days. Patient returned after two days with same complaint and additional symptoms of vomiting and high grade fever. The clinician suspected the case of typhoid and asked for ELIZA assay. The patient started complaining that “why the clinician had not asked if to get the test done initially? And his time and money was wasted on previous medicine”

In this situation Clinician had given the medicine based on the presented symptoms and clinical at the first encounter and his diagnosis was accurate given the context. The missing link was that the clinician never properly consulted the patient regarding the diagnosis and the possible treatment methods, nor the patient was informed about further treatment plan if the condition worsens. Here comes the role of informed consent, the care provider is bound to consult the patient with diagnosis, available treatment option, future plan if the current treatment regime fails or condition worsens. Care seeker should also be explained about possible drug side effects and a written consent should be sought after all the doubts are cleared.  This helps both the care provider and care seeker to establish a mutually synergistic relationship and avoids medico legal issues in future.

Equipoise

Equipoise is more related to drug development and clinical trials. Equipoise is the ability of the clinician to make a judgement on which treatment is better for the patient or which medicine would yield better results on the given condition in particular care seeker.

In clinical practice Equipoise is more related to virtuous behaviour of the care provider.

 

References

  1. Protection of human subjects – 21 CFR Part 50.
  2. Equipoise and the ethics of clinical research. B Freedman. NEJM 317[3]:141-145, 1987.
  3. National Institutes of Health Ethics Program http://ethics.od.nih.gov/.

 

 

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