underlying medical paternalism and patient autonomy is based upon the .. ( indicating that the very idea of the fiduciary relationship in medicine denotes the. expense of the patient's autonomy. Paternalism has been one of the traditional characteristics of the therapeutic relationship in medicine that distinguishes. The right to be seen as a person is something we all expect, but what exactly does this mean? In this lesson, explore the ideas of autonomy and.
Methods Qualitative research was conducted by means of six focus group discussions held in the years and in Croatia. Focus groups were held separately with each of the following: This research specifically addresses issues related to patient autonomy, in particular, the principles of truth telling, confidentiality, and informed consent.
All focus group discussions were audio taped and then transcribed verbatim and systematized according to acknowledged qualitative analysis methods. It has to be understood in context of the broader socio-cultural setting. At present, both patients and medical doctors in Croatia are increasingly appreciating the importance of promoting the principle of autonomy in medical decision-making.
Amy Mullin, Children, Paternalism and the Development of Autonomy - PhilPapers
However, the current views of medical students, physicians and patients reveal inconsistencies. For this reason greater importance should be dedicated to patient autonomy issues in medical education in Croatia. Patient autonomy, Ethics, Paternalism, Transitional country Background Patient autonomy is a fundamental principle of professional medical ethics. The ability to recognize and foster it, and its various dimensions, is widely considered an important clinical competency for physicians.
However, its conception in the medical and ethical literature, as well as its practical implementation, still raises ongoing challenges for the practice of medicine.
Since the release of The Principles of Biomedical Ethics in by Beauchamp and Childress and its subsequent editions now in its 7th editionautonomy has been widely accepted as one of the four principles of medical ethics together with the principles of beneficence, non-maleficence and justice [ 1 ] and has served as the philosophical underpinning for a variety of American reports and Presidential commissions of lasting import [ 2 — 4 ].
However, this influential view of patient autonomy has been criticized from many different perspectives [ 67 ]. Particularly problematic in clinical practice is when autonomy is conflated with the notion of abstract self-concern or with solo decision-making [ 8 ]. Other concepts of patient autonomy are also described in the literature [ 58 — 10 ]. On the spectrum of differing levels of independence, paternalism stands on the opposite side of autonomy.
The objective of paternalism, like that of autonomy, is the good of the same moral agent, the patient [ 9 ]. Paternalism has been one of the traditional characteristics of the therapeutic relationship in medicine [ 9 ]. This attitude presumes that physicians always know better than the patient what is good for the patient. It is precisely this representation of the physician-patient relationship that has suffered the harshest criticisms [ 9 ].
Yet, it is somewhat confusing when, in some jurisdictions like Croatia, on the one hand, medical paternalism appears to be trumped by autonomy, while on the other hand, many individual patients still expect, hope for, and even urge in both subtle and outright ways the doctor to be paternalistic [ 9 ].
It is understandably difficult for practicing physicians to deal with this attitudinal conflict. The aim of this study was to compare and contrast views of different groups on patient autonomy issues in a post-communist, central European country with a strongly paternalistic background Croatia separated from Yugoslavia inand a new democratic state was founded with the first democratically elected president and establishment of the first parliament in the same year.
It is argued that, in clinical practice in Croatia, more emphasis is still put on beneficence and physician-based decision-making rather than on patient autonomy.
Methods A qualitative research was conducted by means of six focus group discussions held in and in Croatia. The focus group method was chosen since it allows in-depth discussion and collection of opinions from more than one person in one session.
Also, data generated through the interaction between group participants, results in a richer elaboration on a topic and a broader insight into understanding an issue than can be obtained from one-to-one interviews [ 12 — 14 ]. Focus groups were held separately with the following: Altogether, 56 voluntary participants took part in this study and all of them read and signed the provided consent form after the main researcher explained the research.
All the students who were given the option to participate consented since the group was held during their medical ethics seminar class.
Patients also were eager to share their experience. Many approached physicians, however, because of their conflicting schedules had to decline participation. Thus, forming a representative group was a significant challenge.
Nevertheless, we formed homogeneous groups with a purposive sampling of a specific population of participants to minimize the influence of one opinion or perspective over others. Number, size, and group composition were formed to ensure participants felt comfortable and free to express their opinion [ 15 ]. Questions were prepared in advance, the same for all, but modified for the patient group.
A moderator LM conducted the first focus group FMled the discussion and took short notes. An assistant moderator GP also took notes and handled logistics. However, for the following focus groups it proved sufficient and practically more feasible to have one moderator LM.
No incentives were offered except for refreshments. This research specifically addressed issues related to patient autonomy, that is, the central principles of truth telling, confidentiality and informed consent. Participants were asked to describe ethical problems encountered in their practice or experience and specifically describe how they addressed these problems, their reactions to them, and any additional comments regarding the situations.
All audio taped materials were transcribed verbatim. We analyzed our focus group interviews bearing in mind the research question we were examining; how the participants viewed different situations regarding patient autonomy issues. Themes were identified independently for each group and then merged together. All themes and comments were arranged with the word-processing method, which was performed by the main researcher LM.
Two additional researchers GP and SS helped in data interpretation by examining trends and patterns.Ethics - Patient Autonomy
Themes that emerged only in one or two groups were also considered. Since much prior research has been performed on patient autonomy issues, we used a directed approach to content analysis [ 1617 ]. Thus, using existing theory, we identified key concepts as initial coding categories [ 17 ]. Data that could not be initially coded was identified and analyzed later to determine if it represents a new category or a subcategory of an existing code.
Results As expected, all participants in the focus groups frequently encountered patient autonomy issues. Generally, these ethical concerns were mentioned in the context of their violation; however, examples of exemplary conduct were also presented. Most medical education in Croatia, as elsewhere, takes place in clinical settings, usually a hospital. Because there is often more than one patient in the room, it is hard to ensure privacy.
Sometimes this is due to irresolvable organizational and practical problems such as: They think that many physicians do not consider patient privacy to be an important issue.
During the discussion with other participants MS1, MS6, MP, ME it became obvious that students and practicing physicians are often unfamiliar with professional duties regarding patient privacy and how to ensure privacy in teaching hospitals. One of the students viewed patient privacy as problematic for learning: At one point her husband entered the room and literally expelled us out [from the room].
MS6 On the other hand, there were times when patients had little hope of privacy and no opportunity to express their wishes; which seemed disrespectful and outdated to some participants.
One of the experienced clinicians recalls: Modern information technologies pose challenges to privacy and confidentiality [ 18 ]. Great effort has been undertaken to protect data personal health informationbut this protection is not consistently applied on all levels.
For example, to obtain coverage from the national insurance fund, patient-identifying data, such as their names and diagnoses, have to be sent to a central office.
There, even though the company and its employees have a duty to respect confidentiality, confidential medical information is still potentially accessible by unauthorized employees. According to hospital physicians, the electronic records of patients in hospital environments, as well as other written documents such as medical histories, are not adequately protected by privacy standards.
All patient data is online. MP Private providers keep family medicine electronic records and some family physicians are worried that the commitment to confidentiality may thus be questionable. Such inquiries are seen as problematic even though they are frequently tolerated. And I had great difficulties to keep that, just technically speaking… because in our community and mentality it is normal that the doorkeeper has the list of all the names and directs the visitors. ME It is often a custom that various medical certificates e.
This is not really an encryption because employers or other parties involved can readily look for the proper meaning of these diagnoses on the Internet.
Family practitioners were especially concerned about this problem since they issue these certificates. Why should the employer have to know which particular disease his employee has? Sometimes purposefully omitting a diagnosis seemed ethically more appropriate. One family physician admitted: She requested documentation of all her past history in order to apply for a job. What to tell A discussion regarding disclosure of a diagnosis arose in all focus groups and addressed two main issues: Regarding the qualitative content of the information, several viewpoints were raised.
As one of the participants vividly described MPtruth in a medical environment is a very thin and malleable concept. Nevertheless, all could agree that in theory one has to be sincere and tell the truth. For some participants, however, the truth can be packaged differently.
Ethical norms should certainly be respected, but it is an art to know when something is possible to tell or not. You need a feeling for that. Some of them admit to having lied sometimes purposefully, or at least omitted the truth, justifying it by claiming that it had a positive effect on their patients. I admit that, at the beginning of my medical career I have sometimes asked the pathologists to write their findings differently and I can tell you that these cases ended well.
Even in cases with highly educated patients involved. Physicians, they said, have to be skilled, educated and aware of how to disclose the truth.
One participant from the patient group explained it vividly: This makes them prone to emotional decision-making and consequently also prone to paternalism. One emotionally understandable but ethically questionable approach was described as follows: I think that it is very important, also from a practical point of view.
Family members have to be prepared for all. They will have to care for him. The patient needs to know what to expect. As one of the experienced physician simply described it: The participants aimed to provide good care. They could take time to talk to and calm patients when required. Sometimes they lacked the time and the patient received medication instead.
There were also strategies in place to prevent violence on the ward. They worried about patients who, in their opinion, did not have adequate support from the social services. Meeting about a home placement for a patient on long-term leave. However, it is the municipality that pays and the officials want a different type of accommodation. However, a few statements revealed that some staff members were loyal to the patient rather than the organisation, despite being aware of the fact that their actions could lead to problems with colleagues.
The participants also wanted to assume responsibility for the patients and their well-being. Some went beyond their professional role by taking more responsibility for patients than was expected. When patients were unable to assume responsibility for their actions, the staff could take over. Sometimes this could lead to situations where patients in voluntary care were treated as if they were in coercive care.
Many of these paternalistic statements convey an impression of staff members acting in a way that they believe is beneficial for the patient. Last week a patient hit a staff member on the head with a plastic bottle. In my view it is both, but above all the purpose is to emphasise that such behaviour is unacceptable. Many participants seemed to be aware of the risk of developing such an attitude, as in their diaries they were critical of colleagues who acted in this way. Several threats to patient autonomy were reported.
One was lack of resources, which sometimes resulted in limitations on patient autonomy. Being permitted to go outdoors and other activities could be limited if staff members lacked the time to assist. Another risk was that ward practices, routines and rules were often extensive, and patients and staff were expected to respect them. Relatives could request information about the patient, which was problematic if the patient did not wish to inform them.
Occasionally the staff decided to withhold information from patients, for example incoming mail or details about their care planning, in order not to create anxiety on the ward. Ward routines included conducting diagnostic tests, and at times management demanded tests, but it could happen that patients refused to participate.
This is a difficult question, which often arises. They reflected on how to perform certain tasks in a way that minimises violation of integrity, e. A young female patient under continuous observation expresses that it is a violation not to be allowed to close the toilet door.
There were also statements revealing thoughts or behaviours where the participant or a colleague had no or only little respect for patient rights. Some participants perceived violations by colleagues and criticized their behaviour or language.
Nevertheless, none of the participants actually noted down that they had reported violations against patients to their superiors and only a few considered doing so. Some statements pertained explicitly to protecting human rights. The other day I had a discussion with a colleague about accompanying a patient who is a Muslim to the mosque.
Reciprocity The participants described striving to involve patients in the planning and implementation of their care. One way to do this was to listen to the patients and ask about their wishes. Although staff members felt pressure from management and colleagues to maintain a professional distance to patients, some participants, especially in child and adolescent psychiatry, chose to have a closer relationship with patients.
However, they did not tell colleagues about their commitment to patients in order to avoid criticism. I received an e-mail from the little Iranian girl today. I have a great relationship with her. The participants expressed the need to build trust between staff members and patients.
They could become frustrated when they failed to create a good relationship with patients and, in the case of child and adolescent psychiatry, with parents. Some participants were committed to their work and clearly shared the joy of patients when they were happy or the treatment outcome was positive. Weight gain, great joy, both for me and the patient. Some participants found it very difficult to control their negative feelings about certain seriously ill patients.
They did not want any kind of reciprocity and instead sought to distance themselves from these patients. He has no empathy towards his victim. I find it very hard to cope with disturbed people.
Discussion The three concepts; paternalism, autonomy and reciprocity, reflect different ethical perspectives in the development of medical ethics in psychiatry. There is a long tradition of paternalism in psychiatry, but patient rights and reciprocity have been considerably more in focus in recent decades. Nevertheless, in this study, paternalism clearly appeared to be the dominant perspective in the diaries analysed.
However, it was difficult to find statements about reciprocity and, of the few identified, most were reflections on staff members working contrary to reciprocity. The reason for this overrepresentation of paternalism in the diaries might be that staff members are aware of the importance of autonomy. Therefore they consider it problematic to act in a paternalistic fashion, although in certain situations it seems to be the only appropriate way.
Another reason could be the ongoing reduction in the number of psychiatric beds in Sweden [ 23 ]. Today, in-patients are in a worse condition than previously and the proportion cared for by coercion has increased.
There are more patients who are incapable of taking care of themselves and making their own decisions. So, the need for a paternalistic perspective and a substitute decision-making may be more necessary today than previously, when patients were not as seriously ill and therefore more capable of assuming responsibility.
There were normative statements that revealed an awareness of patient rights and how staff should behave in order to respect them. However, when describing encounters with patients, the participants stated that living up to such ideals was difficult. In this study as in previous research [ 24 ], there were examples of staff members who more or less routinely failed to respect the right to autonomy, including that of patients in voluntary treatment.
However, in the present study there were also many who criticized such behaviour as well as the use of objectifying language to refer to patients and others.
As argued earlier, the three perspectives should be seen as complementary, representing different valuable contributions. The third and most recent perspective, reciprocity, can make a useful contribution to psychiatry because it focuses on values that have been lacking in psychiatric practice. Both the normative literature [ 15 ] and psychiatric law in, e. Sweden and the UK [ 2526 ], stress that reciprocity, even in coercive care, should be seen as a core value in psychiatric care and that staff should involve patients in all stages of care and treatment, also in coercive care.
A way to foster reciprocity in psychiatry may be to consider it as value-based practice [ 15 ].