Medical ethics: four principles plus attention to scope

Abstract

Respect for autonomy Autonomy - literally, self rule, but probably better described as deliberated self rule - is a special attribute of all moral agents. If we have autonomy we can make our own decisions on the basis of deliberation; sometimes we can intend to do things as a result of those decisions; and sometimes we can do those things to implement the decisions (what I previously described as autonomy of thought, of will or intention, and of action). Respect for autonomy is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected. Respect for autonomy is also sometimes described, in Kantian terms, as treating others as ends in themselves and never merely as means - one of Kant's formulations of his “categorical imperative.” In health care respecting people's autonomy has many prima facie implications. It requires us to consult people and obtain their agreement before we do things to them - hence the obligation to obtain informed consent from patients before we do things to try to help them. Medical confidentiality is another implication of respecting people's autonomy. We do not have any general obligation to keep other people's secrets, but health care workers explicitly or implicitly promise their patients and clients that they will keep confidential the information confided to them. Keeping promises is a way of respecting people's autonomy; an aspect of running our own life depends on being able to rely on the promises made to us by others. Without such promises of confidentiality patients are also far less likely to divulge the often highly private and sensitive information that is needed for their optimal care; thus maintaining confidentiality not only respects patients' autonomy but also increases the likelihood of our being able to help them. Respect for autonomy also requires us not to deceive each other (except in circumstances in which deceit is agreed to be permissible, such as when playing poker) as the absence of deceit is part of the implicit agreement among moral agents when they communicate with each other. They organise their lives on the assumption that people will not deceive them; their autonomy is infringed if they are deceived. Respect for patients' autonomy prima facie requires us, therefore, not to deceive patients, for example, about their diagnosed illness unless they clearly wish to be deceived. Respect for autonomy even requires us to be on time for appointments as an agreed appointment is a kind of mutual promise and if we do not keep an appointment we break the promise. To exercise respect for autonomy health care workers must be able to communicate well with their patients and clients. Good communication requires, most importantly, listening (and not just with the ears) as well as telling (and not just with the lips or a wordprocessor) and is usually necessary for giving patients adequate information about any proposed intervention and for finding out whether patients want that intervention. Good communication is also usually necessary for finding out when patients do not want a lot of information; some patients do not want to be told about a bad prognosis or to participate in deciding which of several treatments to have, preferring to leave this decision to their doctors. Respecting such attitudes shows just as much respect for a patient's autonomy as does giving patients information that they do want. In my experience, however, most patients want more not less information and want to participate in deciding their medical care.