Physicians, autonomy

The pharmacist who obtains patient histories, conducts physical examinations, orders laboratory tests, and prescribes medications must adopt new attitudes and develop new judgment skills. Communication is paramount, both with patients and with other health care professionals, particularly physicians. It has been said that poor communication and emotional issues are at the heart of nearly all medical malpractice actions.Interdisciplinary communication is vital to ease the passage of pharmacists into expanded prescribing roles good communication will enhance collaboration in patient care and diminish perceived threats to physicians autonomy and authority. Obviously, expanded clinical roles for pharmacists will require increased patient contact and strong communication skills. If the patient and the pharmacist fail to understand each other, the pharmacist s risk of liability is increased. 

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. 

The principle of autonomy entails that persons should be treated as inherently valuable individuals with the moral right to make decisions about their own lives. To the extent that one s actions and choices do not negatively affect others, individuals with the capacity to make their own decisions should be free to do as they wish, even if their choices are risky or harmful to themselves. The principle also entails that persons with diminished autonomy, such as those who are illiterate or retarded, deserve to have their interests protected. Many moral obligations for professionals engaged in scientific research or health care are derived from the principle of autonomy, such as the physician-researcher s obligation to fully inform potential research subjects and respect the individual s informed consent or informed refusal. This obligation is founded on the principle that individuals are the appropriate decision makers for choices that do not harm others. 

For more than 50 years, scientists, physicians, bioethi-cists, and the media have focused on a variety of issues in research with human subjects, or clinical research. In 1948, in response to the atrocities perpetrated by Nazi experimentation, the Nuremberg Code was developed to set forth guidelines for the acceptable conduct of scientific research. In 1964 the World Medical Association adopted the Declaration of Helsinki, which specifically guides physicians in biomedical research. These documents specify basic moral guidelines ultimately founded on concerns for autonomy, beneficence, and justice. The guidelines require the following ... 

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. 

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. 

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 ). 

If Lenin approached the proletariat as an engineer approached his raw materials, with a view toward shaping them to his purposes, Luxemburg approached the proletariat as a physician would. Like any patient, the proletariat had its own constitution, which limited the kind of interventions that could be made. The physician needed to respect the patient s constitution and assist according to its potential strengths and weaknesses. Finally, the autonomy and history of the patient would inevitably influence the outcome. The proletariat could not be reshaped from the ground up and fitted neatly into a predetermined design. 

Provision of such services must not jeopardise the counsellor s or the collaborating physician s clinical autonomy, who must at all times be bound to the ethical obligation to take independent medical decisions and exercise his or her medical profession in patients best interests. 

All of these can impinge, directly or indirectly, on the autonomy of patients, and deflect hospital care from the best principles of beneficence for each individual case. Furthermore, Bernard Lo,24 a physician and bioethicist at UCSF, discusses possible pitfalls of ethics committees There can be excessive pressure to reach agreement, impairment rather than improvement of decision making and the broader dangers of Group-think , that is attraction toward consensus overcoming the voicing of independent, and possibly discordant, points of view. 

Rationing of therapies that are thought to be neither suitable nor nonsuitable (there is no proof for or against) which are restricted or denied due to their elevated cost. The conflict in this situation comes about between the principle of beneficence (if the physician orders the treatment) or the principle of autonomy (the patient wants the therapy) and that of justice. No conflict exists if the patient finances his/her own treatment, but it does exist if it is financed by the public health service. Generally, the principle of justice prevails over the other two, and all exceptions should be justifiable. For decisions for rationing to be just (distributive justice), they need to be adopted by the Health Administration. 

The question then arises as to why to bother with a physician in the first place. Diagnostic packages are readily available, and uninsured people (and over 50 million Americans lack full medical insurance) might well opt for a visit to their local internet cafe, where they could obtain diagnosis and prescription, also via the internet, for perhaps a tenth of what a physician would charge. Perhaps the pharmaceutical would come from a pirate source, but there is still a question as to whether this low grade treatment is better than no treatment at all. The above example is an extreme one, but outcomes analysis is here to stay, and medical autonomy is certain to decrease as physicians are squeezed between the empowerment of their clients and the demands of their paymasters. 

While there are a number of ways of understanding science, I have found that viewing science as a profession has been the most useful way to understand the ethics of science. While scientists do not have the autonomy of the practitioners of the classic learned professions, such as physicians and lawyers, in the past century the individual scientific disciplines, including chemistry, have come to regard themselves... 

The socialization of health care in the United States is, for all practical purposes, a fait accompli. However, that reality has been obscured by the absence of a directly nationalized ( socialized ) system of health care, as well as by the American system s being decked out with the vocabulary of choice, market competition, and patient autonomy. The result is deeply ironic the more thoroughly socialized our health-care system becomes, the more physicians and patients alike complain that its shortcomings lie in its capitalistic excesses. 

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