autonomy Archives - Protection of Conscience Project Library

Autonomy, religion and clinical decisions: findings from a national physician survey

RE Lawrence, Farr A Curlin

Abstract
Background: Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors’ decisions. Associations between physicians’ religious characteristics and their weighting of the criteria were also examined.

Methods: Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient’s expressed wishes and values, (2) the physician’s own judgment about what is in the patient’s best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions.

Results: Response rate 51% (446/879). Half of physicians (55%) gave the patient’s expressed wishes and values “the highest possible weight”. In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient’s expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the “highest possible weight”, versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8).

Conclusions: Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians’ decisions as much as is often recommended in the ethics literature.

Lawrence RE, Curlin FA. Autonomy, religion and clinical decisions: findings from a national physician survey. J Med Ethics. 2009;35, 214-218.

Negotiating the Tension Between Two Integrities: A Richer Perspective on Conscience (Conscience in Medicine)

Susan S Night

Extract
I think most would agree that to progress the debate over the role of conscience in medicine we must continue the conversation about the means and ends of medicine as suggested by Lawrence and Curlin (2007, 10). This must be done because the tensions that exist between negotiating one’s personal integrity and one’s professional integrity will never go away. These tensions are not exclusive to the profession of medicine, but are enhanced by potential conflicts between physician integrity and patient autonomy. The objective of the conversation should neither be to eliminate these tensions nor to narrowly compartmentalize them as having religious or secular origins. Rather, the objective of the conversation should be to first encourage each physician to engage in moral reflection upon what they believe is right or wrong and the source that informs these values. Only then will physicians be able to appropriately negotiate the tensions that exist between the moral duties of personal and professional integrity and engage in meaningful dialogue rather than disagreement with their peers and their patients.

Night SS. Negotiating the Tension Between Two Integrities: A Richer Perspective on Conscience (Conscience in Medicine). Am J Bioeth. 2007;7(12):24-26.

(Correspondence) Conscientious Autonomy: What Patients Do vs. What Is Done to Them

CH Browner

Extract
I was intrigued by her argument that an “autonomous” medical decision can sometimes involve simple deference to medical authority, but I’m still unclear what she means when she says that such decisions can be construed as conscientiously autonomous if derived from a patient’s “self trust.” This seems precisely the paradox at the heart of debates over the existence of free will, or in Kukla’s rubric, autonomous choice: is there a “space” outside of social life constituting individual desires where choices derive from what one “really” wants?

Browner C. (Correspondence) Conscientious Autonomy: What Patients Do vs. What Is Done to Them. Hastings Cent Rep. 2005; September-October:4-5.

Private Religious Hospitals: Limitations Upon Autonomous Moral Choices in Reproductive Medicine

William W Bassett

Journal of Contemporary Health Law and Policy

Extract
“Conscience clauses,” protecting the free exercise of religion in ethical decision-making by religiously affiliated hospitals, I believe, should continue to be absolute in reproductive medicine where the hospitals are clearly and unmistakably religious and patient choices of providers are free and fully informed. This conclusion is compelled by the free exercise clause of the First Amendment, as well as by the national interest in preserving and promoting diversity in the voluntary health care sector.

Bassett WW. Private Religious Hospitals: Limitations Upon Autonomous Moral Choices in Reproductive Medicine. J Contemp Health Law Policy. 2001;17:455-583.

Beyond autonomy: coercion and morality in clinical relationships

Maxwell Gregg Bloche

Extract
This article considers the problem of line-drawing between autonomy-preserving and autonomy-negating influence in clinical relationships. The author’s purpose is not to propose particular boundaries, either with respect to reproductive decisions by HIV-infected women or for other clinical choices. Rather, he attempts to shed some light on what drives our disputes about whether one or another influence method is compatible with autonomous choice. The author argues that such disagreements reflect underlying conflicts between normative commitments, and that resolving these conflicts is essential to settling controversies over whether particular influences unduly interfere with autonomous choice.

Bloche MG. Beyond autonomy: coercion and morality in clinical relationships. Health Matrix J Law Med 1996;6(2):229-304.

Beyond Medical Paternalism and Patient Autonomy: A Model of Physician Conscience for the Physician-Patient Relationship

David C Thomasma

Abstract
Medical paternalism lies at the heart of traditional medicine. In an effort to counteract the effects of this paternalism, medical ethicists and physicians have proposed a model of patient autonomy for the physician patient relationship. However, neither paternalism or autonomy are adequate characterizations of the physician patient relationship. Paternalism does not respect the rights of adults to self-determination, and autonomy does not respect the principle of beneficence that leads physicians to argue that acting on behalf of others is essential to their craft. A model of physician conscience is proposed that summarizes the best features of both models-paternalism and autonomy.

Thomasma DC. Beyond Medical Paternalism and Patient Autonomy: A Model of Physician Conscience for the Physician-Patient Relationship. Ann. Intern. Med.. 1983;98(2):243-248.