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Psychiatric patients complicate issue of autonomy

George L. Anesi

Issue date: 10/10/08 Section: Opinion
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Of the four central bioethical principles that guide discussions of clinical ethics, the principle of autonomy has seemingly taken central stage (the other principles being justice, nonmaleficence, and beneficence). This has obvious historical underpinnings; it was grounds for the ferocious backlash against the paternalistic, and often murderous, medicine and research of the 20th century. After the atrocities of the Nazis and domestic ethical catastrophes such as the Tuskegee syphilis study, a sense of urgency was found in the principle of autonomy for competent adults. That is, there should be respect for "the decision-making capabilities of autonomous persons," as defined by Tom Beauchamp and James Childress in their seminal work Principles of Biomedical Ethics.
Autonomy is obviously, however, not always a clearly and clinically interpretable principle it can often be in conflict with the other not-to-be-forgotten bioethical principles, and may also be limited in its application in particular clinical situations. An important instance of the latter is in the context of psychiatric patients who may, for instance, be demanding certain decisions or demanding to live life in a certain way that strikes physicians, psychologists, and other involved parties as somehow dangerous, destructive, or unhealthy.
The well-established principle of preventing an individual from harming him or herself or others recognizes that nonmaleficence, the principle to avert harm, can indeed supersede a claim to autonomy. The idea is also present that in such situations, autonomy may not always even exist as a principle to be overridden, in that its existence relies on the presence of an "autonomous person," which may not clearly be the case.
We often begin an evaluation for the presence or strength of autonomy by considering what the desires and opinions of an individual can illustrate about their state of mind, and indeed the state of "autonomous-ness." The great risk, however, is the creation of a head-spinning, circular path of thought, reminiscent of Joseph Heller's iconic satire Catch-22, in which we claim to respect the right of an autonomous person to, for instance, want to live on the streets, but that an individual's "abnormal" desire to live on the streets suggests he or she may not actually be "autonomous enough" to make such a decision.
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