Over the past 20 years there has been a shift in clinical decision making, impacted strongly by a change in thinking about respect for individual autonomy. This change, while seemingly benevolent, results in an unstable grounding for our ethical decisions.
autonomy killed Hippocrates
For centuries the ruling principle of medical ethics had been paternalism; the doctor deciding what is best for the patient. This was generally accepted as good practice, until relatively recently. In 1994 Beauchamp and Childress set out the 'four principles'. It could be claimed that Beauchamp and Childress have made the biggest impact on medical ethics since Hippocrates decided to live a radically moral life at the turn of the 3rd century BC. Autonomy, beneficience, non-maleficence and justice. Beauchamp and Childress implore every health care professional to uphold these four principles while making a clinical decision, and therefore to promote a 'principlist' approach to ethics. According to principlism the doctor or health care provider should respect the patient's autonomy by allowing him or her to maintain their free will regarding whether to receive treatment. They should act to be beneficent and non-maleficent towards the patient by doing good and not harming, and finally to seek justice by considering the social distribution of resources and the wider benefits and burdens to society. (1)
The Hippocratic Oath and the four principles are similar excepting one stark difference. Within principlism the first principle (autonomy), which has become the over-ruling principle, considers respect for the patient's will, while the Hippocratic Oath assumes a position of paternalism. The Hippocratic Oath is more concerned about doing what is best for the patient including making judgements that 'I consider for the benefit of my patients'. (2)
Respecting a patient's wishes is not mentioned in the Oath, which is instead more focussed on the everyday character traits of a doctor, not just their decisions within working hours.
The Oath has fallen out of favour within the medical sphere as it does not have an emphasis on the personal autonomy of the patient. Irvine Loudon, a General Practitioner and Medical Historian, defends the Oath by reminding us that it is much broader, expanding its influence into the realms of the doctor's private life and imploring the Oath taker always to be moral and upstanding. (3) Beauchamp and Childress attempt to deal with this stance by suggesting that a fifth principle, veracity, should also be upheld to bind the four principles together, ensuring that truthfulness has a central role in the practitioner's life.
holding autonomy higher
Gauging and ensuring autonomy is difficult, and so it is a challenge to measure the positive or negative effect it has had upon medical ethics. The word autonomy literally means 'self-rule' but is often used in the specific context of 'selfdetermination'.
By having autonomy the patient has the right to make decisions regarding the refusal of treatment, whether that decision is deemed wise or not. Some of the most difficult deliberations come when a patient does not possess full autonomous ability, but the grade of deficiency is difficult to establish. Gillon outlines four specific areas where a doctor may act without regard for the patient's autonomy: (4)
- Patients have given their prior consent that the doctor can make decisions as they see fit.
- Respect for one patient's autonomy directly conflicts with another patient's autonomy or safety, or where it would conflict with an aspect of justice.
- Where someone used to have autonomy but no longer does.
- In an emergency where a patient's life is at risk.
Gillon later concedes that patients will often make the autonomous decision to revoke their autonomy for their 'greater good'. An example of this might be where a heroin addict wants to be clean by going 'cold turkey'. They ask to be locked in a room until it is over and make someone promise that they won't give them heroin. The addict is relinquishing their future autonomy (for a short time) for the benefit of being clean. In this way they are working for the benefit of their future self by relinquishing their autonomy until the process has been completed. In the same way patients may lay down their autonomy and trust the doctor to make suitable decisions which would benefit their future selves, even though it might be uncomfortable in the meantime.
putting autonomy it its place
Autonomy is integrally inward looking. By this I mean that if I am being autonomous then I am being self-determining and therefore I am looking inwards to my feelings and my opinions and my rights. This, as with many things in life, has a correct time and place. It is important to be responsible for one's own decisions, and to consider thoughts and feelings on a matter. But doing this to the exclusion of all other considerations or overriding the considerations of others, is not beneficial to you or them. These ideas do not create scope for either community living nor hierarchy within society, and without those society would collapse. This area highlights the chasm between every person's legal rights and their moral duty to others.
The question of what should be the overruling principle in medical ethics comes down to what is in the best interests of the patient and, considering an emphasis on community, for society as a whole.
a Christian response to autonomy
Jesus did not hold his own autonomy higher than the Father's will. In the Garden of Gethsemane Jesus obeyed the Father's higher authority so that we might be saved. We get a glimpse of what this meant for him. 'Going a little farther, he fell to the ground and prayed that if possible the hour might pass from him. "Abba, Father," he said, "everything is possible for you. Take this cup from me. Yet not what I will, but what you will".' (5)
Here we see God in human form, the firstborn over all creation, who made everyone who has any authority, and who rules over all. (6) Even he revoked his own will, knowing that the Father's will was best, so that he would be taken to the cross, and made a sacrifice to enable us to have redemption and forgiveness through Jesus' blood and God's grace. (7)
Paul, in his letter to the Philippians wrote:
'Your attitude should be the same as that of Christ Jesus: Who, being in very nature God, did not consider equality with God something to be grasped; but made himself nothing, taking the very nature of a servant, being made in human likeness. And being found in appearance as a man, he humbled himself and became obedient to death- even death on a cross! (8)
A Christian worldview respects humans because they are made in the image of God, and reflect his glory. Not only that, Jesus became a human and sacrificed himself to take the punishment that we deserve so that we can have a right relationship with God, (9) and from that bestowed dignity upon us. Protecting dignity doesn't make sense if we don't know where our dignity comes from. If we are not made in the image of God, or have an intrinsic dignity, why should there be an act to protect our rights? What rights do we really have? And why should our autonomy be given any respect at all?
As our capacity to make an autonomous decision can be gained or lost, and may fluctuate within our lifetime, is it a good overarching principle for our ethical decisions to be based on? Something rigid and unchangeable would make it easier to approach our dilemmas. It is easily seen that 'working for the good of everyone' would be a good standard to follow, however this becomes challenging where 'doing what is in the patient's best interests' is under debate. Yet we see that the one person who has the greatest right to autonomy, Jesus, still submitted to authority where necessary, able to trust in the character traits of the Father. Shouldn't we be striving to mimic those characteristics and instil the same kind of trust in our patients? Autonomy has become the foundation of modern medical ethics yet holding unshakably to individual autonomy has led to the dangerous situation where what we want is more important than who we are.