Patients autonomy

A conflict can arise between the standard of evidence considered necessary by the administration, the randomized and controlled clinical study (RCT), and the desire of the patient to participate in an open trial, compassionated use (CU). This would mean a conflict between the principle of autonomy (patient) and that of beneficence (administration). 

The existential state of being a patient is perhaps an even more immediate domain of the moral. The loss of autonomy, the fear of the unknown, the dissolution of identity accompanying pain in its multifarious forms, the dehumanization of being subjected to the administrative processes of healthcare, and the psychological dependence each of these challenges fosters combine to make the physician the patient s advocate in a different way to the social one described above. Here, individual concerns are paramount, and the most immediate response must be a humane one. 

Those who feel that the fact of randomization need not be disclosed to prospective subjects argue that since the alternative treatments to be tested are not known to produce significantly different results and since the physician would have to make an arbitrary selection of one treatment or the other for a particular patient, notification that selection of treatment is by computer rather than by the patient s own physician does not provide additional protection for the subjects and is unnecessary. The response to this contention is that a subject s ability to exercise full autonomy over what will be done with his or her own body is best served by notifying the subject as to how the treatment will be selected and by whom, even if the selection process is equally arbitrary whatever process is used. 

Another possible reason for public interest in herbal medications is that they provide some autonomy from medical professionals. Multiple factors contribute to a person s satisfaction with medical care (Siahpush et al. 1999 Sixma et al. 1998 Kaptchuk and Eisenberg 1998). One cause of dissatisfaction results from the traditionally passive role of the patient. Independent of its efficacy, alternative medicine provides an individual with a greater range of explanations and treatment options for their illnesses. The psychological appeal of more options is sufficient to draw individuals to consult alternative medicine, especially in cases where modern medicine has not been effective. 

The principles of autonomy, beneficence, nonmaleficence, and justice form a foundation for analysis of ethical quandaries. In addition, a comprehensive ethical analysis will include considerations of cultural and reh-gious diversity of patient-subjects, health care providers and interpersonal relationships an assessment of the profession-based duties and obligations of the health care professionals, including an examination of relevant professional oaths and codes and an analysis of relevantly similar previous bioethical dilemmas. 

At minimum, the principles of autonomy and beneficence require that patients be told the source of funding for sponsored studies in which they are invited to enroll and advised of any potential conflicts between the physician s research interests and treatment recommendations. 

L D. The principle of justice is a relevant consideration when subjects are selected for clinical research. It requires that members of a vulnerable population, such as institutionalized patients with mental retardation, not be exploited. The principle of autonomy would be most relevant to the parents ability to consent or refuse on the child s behalf, something Dr. Martin thinks is handled satisfactorily. Dr. Martin believes risks have been minimized and the overall study drug is likely to help the participants, so the study has satisfied the principles of nonmaleficence and beneficence. The principle of medical priority is not mentioned in the chapter and pertains to treating the most medically needy patients first, which is not at issue here. 

In older patients toxic multinodular goiter typically presents as longstanding asymptomatic multinodular goiters. Functional autonomy of the nodules develops over time by an unknown mechanism and causes the disease to move from the nontoxic to the toxic phase. The onset of hyperthyroidism is gradual, and the symptoms are usually milder than those of Graves disease. 

As the last two comments suggest, getting well is hard work. The notion that emotionally ill people need to explore multiple avenues leading to wellness is a welcome antidote to a passive patient model. By making people responsible for actively managing their own illnesses, this idea simultaneously restores their personal autonomy and diminishes the power of mental illness. There is wisdom in the following observation ... 

Both verbal and written information should be included as part of the patient and family education. A written set of instructions about taking medications with dates, times, and doses is often helpful. In addition to reading materials provided by the physician or nurse, the patient and family should be encouraged to read about and research the illness and treatment. This collaboration facilitates active learning and helps ensure compliance by giving the patient and family autonomy and control over the treatment. 

Extensive iodine absorption from povidone-iodine can cause transient hypothyroidism or in patients with latent hypothyroidism the risk of destabilization and thyrotoxic crisis (SEDA-20, 226 SEDA-22, 263). Especially at risk are patients with an autonomous adenoma, localized diffuse autonomy of the thyroid gland, nodular goiter, latent hyperthyroidism of autoimmune origin, or endemic iodine deficiency (51). 

Patients with multinodular goiter and thyroid autonomy, especially if they are elderly and/or live in areas of dietary iodine deficiency... 

Indeed, the term therapy itself is misleading, lending itself too easily to a medical model with artificial diagnoses, manipulation, and medication. The term counseling is in many ways preferable and arises out of a tradition that is more respectful of the autonomy and human needs of the individual. Similarly, the word patient is also potentially misleading and might better be replaced with client. But since I am a physician and psychiatrist and do not wish to add undue confusion to this book, with these caveats I will continue to use the terms therapist and patient. 

The appearance of side effects in the course of medication treatment is inevitable. The old, paternalistic attitude displayed by many physicians toward their patients— Take the medicine, and you ll be just fine — provided little patient education and dispensed with patient autonomy. Fortunately, this attitude is gradually being abandoned, and for good reason. We have learned that for treatment to have the best chance of success, an alliance must develop between the physician and the patient, with each contributing to the effort to treat the disorder. A well-informed patient will fulfill his or her role in this alliance more efficiently. A discussion between the prescribing physician and the patient about potential side effects is a must in this context. Since side effects will almost always occur, patients should be aware of them and told what to expect. Such disclosure will generally promote treatment adherence (also commonly referred to as treatment compliance ). 

III. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are xmderstandable. In all cases, a pharmacist respects personal and cultural differences among patients. 

---