This assignment will explain the principle of autonomy and its effect on the professional practise, of nursing. It will also show an example of how the principle has influenced the delivery of care, and will summarise with an understanding of the principle of autonomy. It will focus on the method of care given by both a doctor and a nurse in a clinical setting, and the contradicting styles of delivery. A brief explanation of deontological and utilitarianism values, will support the witnessed experience of the values placed on autonomy in a modern setting.
The account will take an example witnessed from an adult vascular surgery setting, by the author, and include supporting references from extended reading around the subject of autonomy in the health care environment.
In compliance with the, Nursing and Midwifery Council, code of conduct, (2002), Relating to client confidentiality, the names and locations of involved people have been changed, and for the purpose of this account the client will be called Clive.
To appreciate the issues of ethics, and particularly autonomy, in the health care environment, it is important for the nurse to be aware of the fundamental interpretation of its true meaning. (Beauchamp and Childress 2002). The word autonomy comes from the Greek autos ("self ") and nomos ("rule," "governance", or "law"). Its literal interpretation means the right of personal freedom of action. (Oxford Dictionary 2003). It will become evident from this account that the value of being autonomous is governed by a number of factors, some of which the individual has no control over. To act autonomously can also be defined in its simplest term has having the right to decide what happens to your self.
There are occasions in nursing, where the practitioner is faced between a problem and a dilemma. (Katz 1984). A problem can be solved, but a dilemma could be the choice between two or more equally impossible positions. (Berg, et al 2001). The nurse is often called upon to help his patient make an informed decision. This requires the knowledge of the theories, principles, and codes of ethical issues relating to the area specifically at the need for consent for treatments. (Beauchamp and Childress 2001).
Clive is a 56-year-old gentleman that was admitted to the surgical ward for a Splenectomy. He has had no previous surgical interventions and this would be his first extended stay in a hospital as an adult. He has ultimate confidence in the National Health Service, and has supported the hospital for many years, acting as a fundraiser. Clive further more believes that it is the Doctors duty to make decisions in his best interest and he is happy to follow the "Doctors Orders", an observation made clear by the work of (Schneider 1998). This extended trust given by Clive to his Doctor may lead to a degree of vulnerability on his part as discussed by (Baie 1986). Arguably though the trusting stance is central to the doctor patient relationship, and can lead to an enriched view of beneficence (Rogers 1999).
It has become evident that some patients wish to know very little about the treatment which is being proposed, but in its capacity of governance, the General Medical Council encourages doctors to explain to patients the importance of knowing the options open to them and states that detailed information should always be provided. (General Medical Council 2004).
Being so liberal with his consent dramatically affected Clive's delivery of treatment. He was not given the detailed explanations of the process of the operation the effects of the analgesic treatment, required for its commencement, the explanation of likelihood of post operative pain and the consequences of the procedure having un for seen problems, by the doctor that was requesting his consent for the procedure. Although his care was of the highest standards, which we would expect from the service, these points were not made clear for him at the onset of treatment. It can be classified that Clive is a perfect patient that does not ask too many questions and does as he is told. (Stockwell 1974) emphasised that patients who ask too many questions are deemed to be problem patients, a label that may alter their treatment from staff in the ward setting.
Clive's arrival of consent was further assisted by the delivery of communication given by the nurse in charge. She spoke in a clear and professional manner, which was jargon free. The relationship between nurse and patient differs somewhat from the doctor patient, (Stein, Watts, Howell 1990). The staff nurse was able to identify that Clive had not asked any questions at all during the intervention from the doctor and had took a general acceptance of everything he had to say. It was important for her to ensure that Clive had not felt intimidated and over come by the clinical prognosis given to him. She demonstrated her respect for his autonomy, by delivering the procedures in a manor that was clearly accepted by him.
Consent is not the simple filling in of a form, it is much deeper than that, it should form the decision reached by the doctor and the patient, once a detailed explanation of the alternatives, risks and benefits of the treatment have been explored (Katz 1984).
It becomes evident that Clives consent is likely to have been coerced a theory explained by (Dworkin 1988).
Clive has the privilege to withdraw his consent at any stage of the procedure. (Department of Health 1990).
To have the privilege of autonomy in the health care setting, the patient must be able to present himself in a manor that is competent to make an informed choice.(Simm 1986) They must have the capacity to think and act on the basis of such thought and decision freely and independently and without let or hindrance. (Gillon 1986) cited in (Rumbold 1999). There are instances where this clarification is justified by the written guidelines and codes to which the healthcare professional must subscribe (Nursing Midwifery Council code of ethics 2002).
Where a patient is not deemed to have such capacity such as when sectioned under the Mental Health Act of 1983, it is possible for him to be treated without such consent, but only for his mental condition and no other (General Medical Council 2004).
Children under the age of 16 are not deemed competent to give or withhold consent. And a person with parental responsibility may authorise treatments, which are deemed in the best interests of the child. (Bartholme 1995) has made specific comments of these guidelines in his work.
In emergency procedures, it may not be able to gain permission from the patient at the needed time, allowances are made for this but consideration should be given to the known views of the patient, such as religious obligations (Wilcox 1999) or living wills (Goold, Williams, Arnold 2000).
Whilst accepting the criteria needed to be able to make an informed consent and ultimately promote autonomy, the profession must not use its advanced knowledge over the patient, in an act to co hearse treatment. Therapeutic privilege and dated paternalistic approaches of doctors have been documented by authors such as (Veatch 1981) to act as constraints to true autonomy for the patient. Veatch also criticised that the paternalistic approach as acting on patients best interests without the patient's knowledge and consent. Yet, Beauchamp and Childress (1994) argue that paternalism has a valid place in medicine especially when a patient's decision is deemed too risky and he is therefore incompetent.
The healthcare profession has deep routed moral and ethical beliefs of its own, and few would argue that some of its members have stepped out of the parody of the deontologists principles, that it is their duty to help others and abide by the rules at all times. A theory that becomes difficult to follow when faced with a dilemma situation in nursing. (Kant 1724-1804) cited in (Beauchamp and Childress 2002), said that if a rule or duty is right in one situation then it is right in all situations. And that it was a natural inclination to act morally, a philosophy followed by the staff nurse that took some extended time to explain to Clive his precise treatment and consequences of his procedure. (Seedhouse 1988) argues that deontology in the health care setting is impractable, as it would be almost impossible to base health care practice on such a philosophy that advocates individuals making their own decisions. It would be extremely confusing and chaotic it there was no consistency in moral intervention.
Utilitarianism was an approach proposed by Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873) cited in (Kebworthy et al 2003). They discussed that the consequence thought to be beneficial was the greatest balance of good over evil, and to promote the most good for the most people. The surgeon in Clive's situation has adopted that by performing his operation, will restore him to a better position than he finds himself at the onset of the procedure. His utilitarianism value, supported by his therapeutic knowledge has supported his decision in the type of delivery of care to his patient. Many critics of utilitarian theory claim that this approach can lead to decisions that are patently unjust. (Seedhouse 1998).
Whilst exposing the fact that autonomy is a quality that the patient either has, or has not got in the discussed setting, modern day philosophers such as (Held 1990) and (Noddings 1984), argue that the theories of ethics that emphasise right action will never satisfactory provide an account of what is done in practise. They further support their findings and support that the health care workers character will influence the action. The character of the staff nurse can be defined as somewhat different, to the physician when discussing the procedure and respecting the autonomy of Clive.
(Gilligan 1982) found that there was an emphasis on empathy and concern for the well being of others within the caring relationship. She states that nurses and patients have a sense of fulfilment as a direct result of nursing delivered out of a moral sense. To complement this (Noddings 1984) also said that virtuous caring qualities such as accepting the patient's views exist in a caring relationship, such as the nurse-patient. In order to create these conditions the nurse needs to be able to step into the patient's true requirements. The staff nurse knew when Clive needed further clarification of his procedure, and respected his right and moral beliefs not to question the doctor, even when he most probably wanted to know more, or certainly had the right to know more, following the autonomy principles of ethics.
If true autonomy is to be respected then the patients must at all times be given the full details and expected or deemed complications that may occur, during his treatment. The attachment to documented evidence, theory and practice observations demonstrate that autonomy is an issue prevalent to the health care practitioner. Compliance with its legal implications forms only the foundation to its values, the ethical codes to which the profession subscribes to is open to many interpretations, especially when faced with reaching a decision in difficult situations. Whilst the profession will endeavour to support its caring code and deep routed moral obligations to uphold the duty to support life function, compliance with the theory of autonomy should act as a defence mechanism for the patients from the profession possible abuse of these powers.
As at all times an holistic view is taken by multi disciplinary teams for the diagnosis and prognosis of care for the individual, so must the profession take an expanded view of the decisions of the individuals to either accept or decline specific interventions even in the absence of our agreement or understanding for it.
This paper has seen to identify the practice experience of autonomy, by describing the events leading to Clive's treatment and has shown how autonomy fits into the professional practise. The delivery of his care has been identified by his over willingness to consent at the earliest of opportunities, and has concluded with the author's understandings of the principle of autonomy in a health care setting.