The relationship between patient autonomy and a doctor’s responsibility to heal
A necessary and ever pertinent debate!
Context
See https://rogerarendse.substack.com/p/faith-science-and-healing where I describe the context of a 1st semester course - Medical Ethics and a Theology of Health – which I had registered for and completed in 1988 while a student in a one-year postgraduate Bachelor of Arts Honours programme at the University of Cape Town, South Africa
To recap briefly:
Medical Ethics and a Theology of Health comprised twelve (12) weekly seminars which were held each Wednesday.
Half the seminars were devoted to questions of ‘Medical Ethics’ and covered themes which included: the relationship between patient autonomy and a doctor’s responsibility to heal, the theological-ethical issues and criteria involved in procreation, euthanasia and life-support systems, ethical criteria which ought to inform financial resources allocated to medical care, and what it means to tell the truth in a doctor-patient relationship.
The other half of our seminars centred around ‘a Theology of Health’ which included: what are the distinctive characteristics of a Christian theology of health? The significance of the holistic paradigm for understanding health and healing in our context (including dialogue with a biblical perspective, traditional African religion and scientific medicine), faith and the relationship among faith, science and healing, the nature of guilt and its effect on health and the relationship between forgiveness and healing, the theological insights which the Christian faith provides for thinking through the problem of innocent and unjust suffering, and how the Christian tradition understands death and the ways in which this helps in counselling both the dying and the bereaved.
I learnt a good deal throughout this course. To this day I value the content and the kinds of questions we needed to grapple with. I’ve returned to these seminar papers over the years and more especially in more recent times as I have continued to find insights which could support me in my understanding of issues related to Medicine, Science, and Health. I think specifically of the last few years when a so-called ‘Covid Pandemic’ has been forcefully thrust upon humanity across the world, and which has brought into sharper focus many questions and concerns related to (mainstream) medicine, science and health. Even now, four years on, we continue to be bombarded by competing and contested narratives – with a discernible and raging tension between what may be described as Good and True medicine, science and health, as distinct from Bad or Pseudo medicine, science and health.
In two previous substacks, I focused on the component of A Theology of Health and shared these two seminar papers:
Faith, Science and Healing: https://rogerarendse.substack.com/p/faith-science-and-healing
The Problem of Innocent and Unjust Suffering: https://rogerarendse.substack.com/p/the-problem-of-innocent-and-unjust
My focus will now shift to issues covered in the Medical Ethics component of the 1988 course. In separate substacks, I will touch on themes that include: the relationship between patient and doctor (autonomy and beneficence), procreation (abortion and in vitro fertilisation), euthanasia (and life-support systems), and truth-telling in the patient-doctor relationship. In dealing with these themes, I will make very few editorial changes to the original 1988 seminar papers I researched and presented in the course. Now, several decades later, I recognise that each of these themes, and others, requires rigorous examination and critical engagement, especially in light of more recent and ongoing inquiry, research and critical analysis within the medical and health care systems. Hopefully, the content of these substacks offers a helpful introduction to some of the issues which remain important for us today.
The real-life tensions between patient autonomy and the doctor’s responsibility to heal
Within the relationship between patient and doctor, the doctor seems virtually bound by the Hippocratic Oath which obliges him/her to “benefit patients, as well as not inflict harm” (Beauchamp & Childress 1983:149). But in the actual real-life situation, a tension (paradox) emerges which limits the rigid and absolute adherence to this Oath, and its necessary reinterpretation in the actual patient-doctor relationship. This tension arises from the principle of autonomy which grants the patient the moral right to decide for or against the particular ‘benefit’ which the doctor may deem necessary at the time.
The relationship between patient autonomy (the principle of autonomy) and the doctor’s responsibility to heal (the principle of beneficence) is thwart with complexities in the real-life situation. These complexities stem from the critical ethical question which arises all too often:
Is the authority of the doctor at all compatible with the patient’s autonomy?
In this post, I will seek to identify and discuss critically the relationship between patient autonomy and the doctor’s responsibility to heal, in an attempt to find some answers to this question. The principle of autonomy in its root sense underscores the patient’s individual right (Mill) and moral right (Kant) to determine, decide and legislate for his/her own life without the coercion or authority of the doctor being applied to deny this autonomy. The doctor’s responsibility to heal relates primarily (not exclusively) to the principle of beneficence which in its fundamental sense specifies the doctor’s obligation or “duty to confer benefits and actively to prevent an remove harms” (Beauchamp & Childress 1983: 148), and “to balance possible goods against the possible harms of an action” (ibid:149) for the patient.
If each of these principles (of autonomy and beneficence) were treated as absolute moral ideals, then one can only conclude that they are by their very nature incompatible. Therefore, any meaningful relationship between patient and doctor would be practically impossible unless patient autonomy and doctor’s beneficence showed a one to one agreement in all situations. For example, if a patient agrees to a kidney operation proposed by the doctor in order to benefit the patient, this compatibility or tension-free relationship is all too often complicated by a myriad of human and social factors. So the thesis question remains. Restated, it asks:
What are some of the identifiable factors which test/challenge the patient-doctor relationship, and how are these factors faced in order to overcome the incompatibility which may and do arise in this relationship?
In order to answer our central question (both in its original and restated form), it may be helpful to ask FOUR further questions which may emerge in the patient-doctor relationship. A critical reflection on these questions, I believe, will highlight in part the dynamics of the relationship between patient autonomy and the doctor’s responsibility to heal.
Question 1: How is the issue of ‘informed consent’ with regard to the patient linked to the doctor’s authority to either disclose or withhold information which s/he believes may respectively help or hinder a patient’s decision in a given situation?
The functions of informed consent outlined by Alexander Capron moves logically to a bias that “the primary function of informed consent is the protection and promotion of individual autonomy” (Beauchamp & Childress 1983:67). In order to reflect this bias, the doctor is committed to avoid withholding important information from the patient which may hinder the patient’s autonomous choice. The doctor is responsible to disclose that information which the autonomous patient can comprehend and help him/her decide about the particular treatment or refusal of such treatment. (This begs the question as to who decides what the patient can comprehend). But the doctor’s unconditional disclosure of information to the patient in order to respect the patient’s autonomy would be morally foolish if the patient is rendered incapable of autonomous decision-making because of severe depression or extreme duress. In this situation the doctor’s intentional decision to withhold certain aspects of information would, in accordance with ‘therapeutic privilege,’ be justified in overriding patient autonomy. The health of the patient is considered the important issue and the doctor is considered morally obligated to protect the patient from harm and to seek his/her health. The doctor justifiably becomes the necessary authority in determining ‘informed consent’ in the situation.
A perplexing situation does arise in the patient-doctor relationship when the unstable, non-autonomous patient, or even the fully autonomous patient “willingly submits to that authority, and when the authority figure uses that commanding position for purposes of control” (Beauchamp & Childress 1983:89-90). While the doctor’s strict commitment to the principles of beneficence or non-maleficence and his/her respect for the patient is the saving grace in the situation, it is inevitable that at least a minimal degree of conscious or unconscious doctor manipulation of the patient will occur in the relationship. But the doctor’s integrity can be safeguarded if truth-telling on the part of the doctor frees itself from a rigid application of teleological or deontological principles. The actual situation must be taken into account. And in the end, the doctor realises that he/she, in this matter of medical ethics, is never absolved from what, in some situations, amounts to the ‘terrible responsibility’ of decision-making.
Question 2: How does the principle of positive beneficence - that is the provision of benefits, including the prevention of harm, and the removal of harm - confront the patient’s autonomous or non-autonomous refusal of treatment?
It seems that the decision by the patient who is deemed non-autonomous, incompetent, and non-voluntary by medical and legal standards, permits and even requires the doctor to “err on the side of preserving life” (Beauchamp & Childress 1983:93).
But the refusal of treatment by a competent and autonomous patient within the framework of ‘the law’ does favour patient autonomy over the doctor’s responsibility to heal (ibid. 91). The outcome here is devoid of moral tension if the patient receives the treatment and recovers. But the strain is evident when the patient’s condition deteriorates, or he/she dies as a result of the doctor’s desire to satisfy patient autonomy. The doctor’s responsibility to heal, in this context, is interpreted by the law, perhaps unfairly, as a virtual absolute. The doctor now faces charges of acting unethically or immorally, and at worst can be dismissed from the profession. I would argue that the stable doctor who understands and is committed to the Hippocratic Oath would never allow this to happen. On this assumption (that doctor, in such cases, always knows better than the patient) , it would follow, therefore, that the doctor’s authority and responsibility to heal must always take precedence over patient autonomy in their relationship, given the specific circumstances described above. (Of course, this assumption needs critical (re)examination in light of changing circumstances).
Question 3: How does the cost-risk benefit analysis (the principle of utility) affect patient autonomy and the doctor’s responsibility to heal?
I agree with Beauchamp and Childress that a cost-benefit analysis for decision-making within the patient-doctor relationship is “acceptable and indeed commendable if it encompasses a wide range of values…and if it respects such constraining principles as autonomy and justice” (1983:160). But it seems evident that the doctor’s authority is primary in the situation and the onus is on him/her to determine the risks of a particular treatment or the benefit this treatment may or may not have for the patient. He/she is at liberty to refer the patient to other colleagues, or at least seek a second opinion. However, unforeseen factors are inevitably at play here, and the relationship between patient and doctor can become rather precarious as human weakness and fallibility enter in.
Question 4: How does patient autonomy relate to the paternalism of the doctor in the professional health situation?
Beauchamp and Childress (1983:179) are justified in rejecting anti-paternalism (which leaves no room for the principle of beneficence), and strong paternalism as too idealistic.
Weak paternalism offers a better solution in maintaining both patient autonomy and the principle of beneficence. This takes a greater account of reality, where “on many occasions persons are genuinely not capable of making autonomous judgments about their best interest, and an external authority’s decision may be perfectly in order in these cases”.
Conclusion
Allopathic medicine has come under greater and justifiable scrutiny during the Covid pandemania, and so have medical practitioners in service of this mainstream approach to medicine and medical care. And it is as certain that medical ethics has taken immense strain and often come under direct and indirect assault. Numerous stories now are told of the violation of the doctor-patient relationship– more so over the last four years.
The ethical issues raised above, and many others, require critical and necessary re-examination and re-evaluation today.
Medical ethics must be kept sharply in focus!
Reflection and Journalling Exercise
What are the important matters to keep in mind when considering the relationship between patient and doctor today?
What is your understanding of the relationship between ‘patient autonomy’ and ‘the doctor’s beneficence to heal’?
Is the Hippocratic Oath still an important and necessary framework for the practice of medicine today? Why do you say so?
What do you understand by ‘informed consent?’
To what degree does medical ethics still function in allopathic medicine?
References and resources
Beauchamp, T.L. and Childress, J.F. 1983. Principles of Biomedical Ethics. 2nd edition. New York: OUP
The Hippocratic Oath – Classic and Revised Versions
https://doctors.practo.com/the-hippocratic-oath-the-original-and-revised-version/
https://en.wikipedia.org/wiki/Hippocratic_Oath
Thank you for making time to read this substack.
Kindly consider sharing with others who you feel may be interested and could benefit from the content.
Look out for a forthcoming substack that will explore the issue of procreation, abortion and in vitro fertilisation from a theological-ethical perspective.
Blessings!