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Is Autonomy All We Really Want?

"The Doctor" by Luke Fildes. Courtesy WikiMedia Commons
“The Doctor” by Luke Fildes (1887). Courtesy WikiMedia Commons

As recently as the 1960s, physicians made almost every decision for patients, informing them of their choices and rationale. Now, the paternalistic era of “doctor knows best,” one aligning with the ethical principle of beneficence, has been largely replaced by the emergence of patient autonomy in health care. The pendulum, however, may have swung too far. “Doctor knows best” is history. “Patient knows best” seems to have taken its place, allowing the triumph of individualism to cast beneficence into the heap of collateral damage.

Exercise of a doctor’s clinical judgment is frequently attacked as “paternalistic.” While true in some instances, it may also be justified in others. When physicians bore more decision-making responsibility, they also had more opportunities to practice beneficence. They shouldered much of the burden of difficult decisions when they took responsibility for deciding when to inform patients of fatal diagnoses, when to withdraw ineffective care and when to announce that death was near. However, when such an approach diminished the rights of patients to be well informed in making decisions for themselves, the scales appropriately tipped toward autonomy.

Now, it seems, the scales have tipped too far. With our “customer is always right” approach, the primacy of autonomy has shifted the burden of decision-making to patients and families who have limited medical knowledge.

Franz Ingelfinger, a past editor of the New England Journal of Medicine, stated, “A physician who merely spreads the options in front of the patient and says, ‘Go ahead and choose, it’s your life,’ is guilty of shirking his duty…a physician should recommend a course of action…and must take the responsibility, not shift it on the shoulders of the patient.” But, the medical ethics principle championing the right of self-determination makes this position murky for physicians, demanding that they tread lightly. I argue that we need to right the ship.

FORPATIENTSGOODThankfully, we are now starting to see a moderation of the emphasis on autonomy and an introduction to the model of shared decision-making. This balance allows beneficence to emerge more prominently as one of the guiding principles of medical ethics. The most articulate spokesman for promoting medical beneficence was Dr. Edmund Pellegrino, Professor Emeritus of Medical Ethics at Georgetown University. In For the Patient’s Good: The Restoration of Beneficence in Health Care, he envisioned the principle as a complement to autonomy, viewing medical practice as enriched by the partnership.

The real encounter happens in this shared space, the “space between,” where we seek partners to help with hard decisions. Are we struggling to live or struggling to die? Autonomy leaves that decision up to the patient or surrogate; however, it is an isolating and frightening choice. A model that best fits the optimal patient-doctor relationship is one in which there exists mutual, unspoken agreement between parties, recognizing duties and obligations to each other. Bilateral trust is at the heart of this relationship. It requires full disclosure by the physician and respect for each party’s perspective.

A way to minimize isolation and stress associated with life and death decision-making is to accept a paradigm of “dialogical encounter,” introduced by Russian philosopher Mikhail Bakhtin. The dialogic does not accept “one voice speaking in a way that other voices are unacknowledged, unheard, or even subsumed.” It rejects that only one perspective is privileged. Dialogism denotes multiple voices that listen to each other, share ideas and encourage difference. And, as theologian Mark McConnell adds, “It is in this space of difference, collaborative solutions arise.” Aloneness is left at the door.

Medical ethics and its autonomy principle have allowed us to move beyond unchecked paternalism. However, the field can now draw us back to the middle; there, interdependent beings can share, with due respect, in an I-Thou relationship where some of the hardest decisions are made. This is the essence of true beneficence. It complements autonomy. After all, our shoulders are only so broad.