NU 500 Theoretical Foundations of Advanced Nursing Practice
December 7, 2011
Patient Autonomy: A Concept Analysis
The concept of patient autonomy is a highly variable subject in all fields of healthcare. Patient autonomy has been analyzed in many different ways in the literature. There has been several research studies conducted over the past several years, and the concept of patient autonomy is still somewhat undefined. It is crucial to analyze the concept of patient autonomy for various reason, but most importantly, to inform the staff in the healthcare setting about the importance and the significance of patient autonomy.
Patient autonomy is a universal concept that varies widely in its meaning and interpretation. Autonomy in its simplest form can be defined as a state of independence or self-governing (Atkins, 2006). Patient autonomy can also be defined as the ability to make one’s own decisions, based on one’s sound judgment. Autonomy can also be defined as the ability to utilized the information the nurses and doctors have provided the patient with to make the most logical and safe choice for the healthcare decision. Patient autonomy is also the patient’s ability to advocate for themselves, and to self-read and understands what decisions are going to be the best over a long period of time. A patient’s autonomy can be verbally expressed through their words, or through advanced directives or living wills. There are several explanations for autonomy, although the simplest definition of autonomy is allowing a person of sound judgment to make their own healthcare decisions without interference from physicians or nurses. For the purpose of this concept analysis, patient autonomy is defined as having the ability to make an independent choice pertaining to one’s own healthcare situation (Akins, 2006).
Therefore throughout this concept analysis, the concept of patient autonomy will attempt to be defined, and the true meaning of autonomy will be analyzed. Along with the definition of autonomy, this concept analysis will attempt to identify the variable states of autonomy, and how that variability can affect patient care and patient safety in the hospital setting.
Review of Literature
A search was conducted using CINHAL Plus, SAGE Premier, and Google Scholar databases between September and November 2011 to investigate and research on the concept of autonomy. Keywords that were used in the Boolean/Phrase searches included autonomy, concept analysis AND autonomy, patient AND autonomy, ethics AND autonomy, legal AND autonomy, patient autonomy AND hospital, culture AND autonomy, and autonomy AND philosophy. All three of the electronic databases were carefully sifted through to find articles there were most pertinent to the studying of patient autonomy within the concept analysis. Articles were selected on their tittle, subject matter, content of the abstract, ability to view and download articles and their research pertaining to patient autonomy. All of the searches for autonomy generated over 20,000 links between the three research databases, so therefore not all links were used for the concept analysis. The articles that were used for this paper were carefully analyzed by both authors, Dallas Dooley and Susan Swords.
Atkins (2011) addresses the conception that autonomy is based on freedom of choice. This conception is proven wrong, and it is shown that autonomy is indeed a very personal choice that uses the person’s self-recognition, self-conceptualization, and self-reading to make the sound choice for one’s self. Atkins presents a general concept of autonomy that is relatively universal, and easily understood. She then speaks about Diana Meyers’s view of autonomy as relational and practical. Atkins goes into great depth on Meyers’s theories of autonomy and compares her views to that of other philosophical theorists. And she concludes the article by presenting ways the nurse can effectively advocate for autonomous relationship with the patient.
Atkins feels that universally autonomy is thought to be a liberal concept of informed and uncoerced decision making that displays a fully rational person’s own free will. She identifies several shortcomings to this general conception. For instance, she identifies the dementia patient that at times has fully rational thinking, but at other times has a completely irrational thinking process. She also identifies the underage “minor” that is very well educated, and knowledgeable, but is unable to make their own healthcare decisions because they are not old enough. Or a teenage girl that may be considered insufficiently physiologically and rationally developed to consent to sex or surgery, but is able to take responsibility for a child she has mothered, and is able to consent to surgery for that child. Atkins feels that the general concept of autonomy being one’s own free will is completely inadequate, and there are several other factors that are incorporated into the decision making process. Atkins feels that Dianna Meyers’ ideas of autonomy are more realistic and in-depth.
Meyers feels that autonomy consists of a set of socially acquired practical competencies in self-discovery, self-definition, self-knowledge, and self-direction (Atkins, 2011). Thus a personal choice is fundamental to autonomy, and autonomy is a fundamental element of ethical life. She feels for a person to truly understand autonomy they must have self-knowledge and an understanding of their view of on their future, and their life-decisions. John Stuart Mill in 1859, created one of the most understandable cases for autonomy. Mill felt that all adults or rational individuals should be regarded as equals. He felt that autonomy “is the right to determine for oneself one’s interests, goals and values, and one’s own conception of a good life free from unwarranted interference” (Atkins, 2011).
Meyers doesn’t agree with many of the mainstream theories such as Gary Watson, Robert Young, and Gerald Dworkin, and feels that autonomy is not just based on one’s free will, it is based on self-definition, or the effort to cultivate a certain kind of will or personality in oneself . Meyers' relational view of autonomy states that one displays personal autonomy, they are employing specific cognitive and practical capacities that are not simply defined as one’s free will. Meyers feel that a person must have a life plan, and be able to self-read to make choices that are autonomous and in the best interests of one’s self. By self-reading she means the patient must be able critically reflect upon their self and understand their own self-conceptions, and drives that motivate their choices. For the nurse to adequately apply autonomy to the nursing practice, that nurse must be able to promote self-learning to the patient. The nurse can’t simply provide the patient with the information and allow them to make their choice based upon the nurse’s information. The nurse must have the patient self-read, and determine what choices are best for that certain patient.
Leever (2011) sets out to identify the link between cultural competency and autonomy. Leever explains that autonomy is viewed differently by different cultures. It is found that the American culture has a sense of power, and the citizens feel empowered to make their own decisions. In countries in Africa and the Middle East, women are still thought of as second class citizens, and they don’t want to have to power to make choices. Within this paper, Leever presents three case studies in which each patient was from a culture different from the United States.
The first case study was an Iranian woman who was in labor and was waiting to be examined by a gynecology resident. When a male resident entered the room, the patient’s husband became very upset and requested a female resident. Once the female resident began assessing the patient, that patient referred all questions to the husband to answer. It was found in Middle Eastern culture that woman are not comfortable with male physicians, and the typically rely on their husbands to answer the questions for them.
In the second case study analyzed a young Korean man that was in the United States and began developing renal and respiratory failure. The doctor put the patient on strict bed rest and given a bedpan for toileting to prevent further illness. The problem came when the patient would place the bedpan on the ground and squat over the pan to move his bowels. The nursing didn’t understand why he wouldn’t use the bedpan in the bed like normal. They found out that in Korean and many Asian countries, toilets are usually just holes in the ground, and it is thought of unsanitary to defecate in the bed. The patient was essentially doing what he thought was most appropriate for the situation he was in.
The third case study is of a Jehovah’s Witness patient who presents to the hospital and needs an immediate cholecystectomy to remove the diseased gall bladder. The patient is alert and orient and reports that he cannot consent to surgery because he cannot receive blood transfusions due to his religious preference. The nursing staff reports that the hospital is able to perform a bloodless surgery and allows him to consult with an experienced representative about the bloodless surgery. The patient decides to proceed with the cholecystectomy.
Leever’s research focuses on how each of these cultures might view autonomy in a different way. For instance letting the man from case study two defecate on the ground was the most productive thing the medical staff could allow to promote autonomy to the patient. Leever wanted to explain how the collective cultures throughout the world view autonomy in different ways. He feels the public should not assume an incompatibility with autonomy from different cultures, because they might feel differently than most people would. Leever also feels that autonomy is so mistaken for selfishness, and all autonomous decisions are made to promote one’s own good to the exclusion of others. He feels that simply because a person is acting on their desires, doesn’t make their decisions selfish. He provides an example of an elderly woman who is very ill in the hospital and wants to refuse treatment because she doesn’t want to be a burden on her family that is attempting to care for her. With that autonomous decision being made, it is quite clear the elderly lady is not action in a selfish manner.
Finally within the article Leever displays Bruce Miller’s common senses of autonomy. The first common sense of autonomy is that of free action. By this he means, a person is able to be autonomous without coercion or constraint. They may act on their own individual liberties. The second sense of autonomy is that of effective deliberation. By this Miller means that one is able to understand the facts and one’s circumstances to make informed, rational choices and decisions. And the third common sense is of autonomy is authenticity. This refers to coherence between one’s beliefs, values and choices. If a person were to act authentically they would be staying true to their own beliefs. With these three common senses of autonomy described, the patient should be able to make the decision that is best for them and their culture.
Frank et al. (2011) wrote about the Supreme Court’s decision to prevent physician assisted suicide in the state of Washington. It was found that the current laws in the nearly every state do serve dying patients well, and do not provide the support that the families need when a patient’s end-of-life wishes are not honored.
The state of Washington has a ban on physician assisted suicide (PAS), although it is thought that the ban is a violation of the Due Process Clause of the Fourteenth Amendment of the U.S. Constitution. The Due Process Clause “prohibits states from making laws that deprive any person from life, liberty, or property without due process of the law; nor deny to any person within its jurisdiction the equal protection of the laws” (Frank & Anselmi, 2011). This particular case was presented to the U.S. District Court in 1994, and the respondents Harold Glucksberg included three physicians, three terminally ill patients who died prior to the hearing, and a representative for Compassion in Dying, a non-profit organization that offers counseling to those considering PAS. Glucksberg and his associates felt that the Washington state’s ban on PAS was unconstitutional.
Originally, the U.S. District Court came to the side of Glucksberg and felt that it too was unconstitutional, and the state’s ban was invalid. The case then went to a Court of Appeals and they too felt it was an invalid law and unconstitutional. It wasn’t until 1997, that the state of Washington petitioned the case and it was taken to the Supreme Court. The Supreme Court found that “prohibition against ‘causing’ or ‘aiding’ a suicide” does not offend the Fourteenth Amendment to the United States Constitution (Frank & Anselmi, 2011). The U.S. Supreme Court assigned Chief Justice William Rehnquist to this case.
Rehnquist came up with five different circumstances that expressed PAS was unethical and unconstitutional, and inevitably, illegal. Rehnquist felt that the court was interested in protecting a patient from making a permanent choice, at a time of temporary imbalance. Essentially, Rehnquist was saying he didn’t want to have a patient take part in PAS when they would recover from their illness and continue to live. He also felt that the court had to safeguard all people’s lives, and compared PAS to homicide. The third issue the court found is that the AMA Code of Medical Ethics does not support PAS, and feels that PAS does not support the physician’s role as a healer. On the fourth issue, Chief Justice Rehnquist felt the court had the right to protect the vulnerable from making a life ending decision. He felt he needed to protect the people that have trouble making sound choices for themselves. The final issue Rehnquist found is that PAS could lead to euthanasia. He felt that if PAS was readily assessable to the general public, it would promote euthanasia. The problem came in the fact that Rehnquist never once spoke to the rights of the patients, and their autonomy as a patient in the healthcare setting.
Bӕrøe K. (2010) discusses the qualities that make a person competent versus non-competent in order for them to be autonomous. Bӕrøe addresses a difference between personal and moral autonomy with personal autonomy meaning that people are able to make personal choices that are guided by one’s desires and personal goals. Moral autonomy focuses on moral constraints that hinder one’s decisions. Bӕrøe also distinguishes differences regarding informed consents. She points out that patients must have the autonomous power in order to make an “autonomously authorized consent” or an “effective consent”. Autonomous authorized consent is where the patient makes a deliberate decision regarding their care. Effective consent refers to making a decision that complies with the laws or hospital policies. Bӕrøe addresses that patients must be assessed for voluntariness and competence. Patients must act, or make decisions voluntarily without being persuaded, coerced or threatened. An example of a patient being coerced is a physician stating “This is your only treatment we can offer” (Bӕrøe, 2010). In order to be a competent patient, according to Bӕrøe, one must make a decision that the majority of people would make. She also explains that patients must meet a certain threshold and that threshold must be at a precise level or it may deem a patient incompetent when they are actually competent.
Davies, M., and Elwyn, G. (2008) investigate the negative effects of over-promoting patient autonomy in circumstances where autonomy may not be the best for the patient’s physical, intellectual or emotional situation. Davies and Elwyn report that if healthcare providers believe in autonomy, then they must also believe that patients “have a presumptive obligation to make health care choices and health care insurance choices” (Davies & Elwyn, 2008). Davies and Elwyn illustrate various arguments regarding autonomous decisions which include: a moral argument, prophylaxis argument, therapeutic argument, and the false consciousness argument. The moral argument is based around that patients should be autonomous in their decisions. Prophylaxis argument states that patients must be compelled to challenge the power of providers. In the therapeutic argument, when patients are autonomous and make autonomous decision, their health improves. False consciousness argument stress that patients need to be forced out of their dependence on providers (Davies & Elwyn, 2008).
When autonomy is over-promoted or mandatory, according to Davies and Elwyn, the patients who are more highly educated and affluent will have wider choices in their healthcare options compared to those who are in lower in socioeconomic states and those who are less educated. Additional restrictions include a patient’s social, cultural and economic status (Davies & Elwyn, 2008).
Sakalys, J.A. (2010) discusses a how patient autonomy may not be realistic in all patient care settings and with every patient. Sakalys differentiates between “ideal” and “real” autonomy where ideal autonomy is where all patients are self-sufficient, able to make rational decisions, and deems the patient as the final authority over their decisions, with complete understanding of what is at stake and without internal or external influences (Sakalys, 2010). Ideal autonomy comes with extenuating factors that prevent it from being reality in all patient situations. Some of these extenuating factors include conflicts between: autonomy and justice, autonomy and dependency and vulnerability, and between autonomy and other situational constraints (Sakalys, 2010).
Clinical issues that arise with patient autonomy include the disproportionate power relationship between healthcare provider and patient. Healthcare providers have greater expertise regarding medical knowledge that the patient does not necessarily possess. Sakalys notes that patients actually prefer having a shared participation role where the problem solving is made by the provider and the decision-making left to the patient while others chose to assume a passive role and a small number of patients choosing to assume a complete autonomous role (Sakalys, 2010).
Sakalys reports that in order for patients to be autonomous a lot of determining factors rely on the patient’s resources which include: “competence, decision-making capacity, social status, economic and social resources, knowledge, professional position, and previous healthcare experiences” (Sakalys, 2010). The severity of the patient’s illness will also play a part in their ability to make autonomous decisions. Patients suffering from severe or life-threatening situations may not be able to make decisions regarding their healthcare, such as patients who are in a coma or heavily medicated. Thus the ideal concept of autonomy may not be appropriate in all situations. Autonomy needs to be adjusted on a patient basis and cannot be the same in all circumstances.
The purpose of defining attributes of a concept is to help distinguish autonomy from other concepts. Throughout the literature review, some common themes appeared that defined autonomy that included: freedom of choice, knowledge, power or empowerment, competence, and individualized (See Figure 1). Each of these attributes shape how patients are able to make or not make autonomous decisions.
A 25 year old woman presents to the emergency department (ED) with complaints of dysuria. The physician explained to the woman the need for a urine specimen. The woman was given the option of providing a clean-catch urine specimen or having a straight catheterization performed. The patient was informed of the differences between the collection techniques and chose to provide a clean catch specimen as she felt the catherization was unnecessary.
Contrary Model Case
A 55 year old woman presents to the ED with complaints of a headache. The patient reports that her headache is similar to her normal migraines. The physician orders a head computed tomography (CT) to evaluate for possible cerebrovascular accident (CVA). The patient refuses the head CT and requests pain medications as she feels this is another of her normal migraines. The physician tells the patient that she won’t be receiving pain medications and can sign out against medical advice if she doesn’t have the CT.
Since patient autonomy is such a dynamic processes and inevitably the patient’s final decision, it can be somewhat difficult to isolate definite antecedents that precede the development of patient autonomy. Although with all of the research that has been conducted, it has been found that there are several complex processes that can influence patient autonomy. Literature has shown that there are internal and external antecedents that lead to the promotion and execution of patient autonomy.
The internal factors that promote patient autonomy are often found in the patient’s cognitive and emotional thought processes. The most prominent factors included self-recognition, self-reading, perception of care, willingness to make decisions, and perception of their long term future. All of these factors can be influenced by a nursing staff, but can only be controlled the patient themselves (see Figure 2).
The most prominent external factors that lead to patient autonomy are the nurse’s influence on the decision process, the family presence and influence, along with communication between the nurse and patient. Along with these factors, the physical environment of the treatment facility, the professionalism and respectability of the medical staff, and the countries legal process have significant influences on patient autonomy. Patient autonomy is significantly influenced by the combination of both the internal and external processes. When both of these factors are positive and motivational, the patient will be more likely to make a sound, autonomous decision.
The outcomes or consequences of patient autonomy are much easier to identify than the antecedence or definitions of autonomy. For the most part, the consequences of autonomy are positive. The literature shows that when the patient has the opportunity to express their wishes and make their own decisions, they are much happier with the care provided and are often times much more satisfied with their hospital stay (see Figure 2). Personal satisfaction, freedom, self-confidence, and satisfaction with their decisions to make their own choices were also most notable (Spear & Kulbok, 2004). Unfortunately, there have also been some negative effects of patient autonomy. One of the most notable negative effects can be patient’s non-compliance that in effect leads to death or serious injury. In the case of physician assisted suicide, the legal processes of the state of Washington prevented the patient from making an autonomous decision for their healthcare (Frank & Anselmi, 2011). Therefore, when the patient has the right to make their own decisions, their satisfactions is improved, and their state of health typically improves.
In order to deem that one is autonomous, healthcare providers need to take steps to ensure that the patient is indeed able to make their own decisions. Observation is the best way for healthcare providers to determine a patient’s capability for making autonomous decisions. For the purpose of this concept analysis a questionnaire was developed in order to determine whether or not the patient has the mental capacity to make an autonomous decision (see Figure 3). If it is determined that a patient cannot make an autonomous decision, then providers must assist patients in obtaining all the required information so that a shared decision can be made.
Autonomy is a complex concept that healthcare providers must seek to incorporate into their daily practice as patients desire to have and make autonomous decisions whether those decisions are solely autonomous or made in a shared decision-making capacity. However, it is essential that providers consider the patient’s mental, educational, socioeconomic, and cultural status, if the patient has been fully informed and the severity of their illness as all of these factors play a part in the patient’s ability to make decisions.
Atkins, K. (2006). Autonomy and autonomy competencies: a practical and relational approach. Nursing Philosophy, 7, 205-215.
Bӕrøe, K. (2010). Patient autonomy, assessment of competence and surrogate decision-making: a call for reasonableness in deciding for others. Bioethics, 24(2), 87-95. doi: 10.1111/j.1467-8519.2008.00672.x
Davies, M., & Elwyn, G. (2008). Advocating mandatory patient ‘autonomy’ in healthcare: adverse reactions and side effects. Health Care Anal, 16, 315-328. doi: 10.1007/s10728-007-0075-3
Frank, R., & Anselmi, K. K. (2011). Washington v. glucksberg: Patient autonomy v. cultural mores in physician-assisted suicide. Journal of Nursing Law, 14(1), 11-16. doi: 10.1891/1073-74126.96.36.199
Leever, M.G. (2011). Cultural competences: Reflections on patient autonomy and patient good. Nursing Ethics, 18(4), 560-70. doi: 10.1177/0969733011405936
Naik, A.D., Dyer, C. B., Kunik, M.E., & McCullough, L.B. (2009). Patient autonomy for the management of chronic conditions: A two-component re-conceptualization. The American Journal of Bioethics, 9(2), 23-30. doi: 10.1080/15265160802654111
Sakalys, J. (2010). Patient Autonomy: patient voices and perspectives in illness narratives. International Journal for Human Caring 14, (1), 15-20.
Spear, H.J., & Kulbok, P. (2004). Autonomy and adolescence: a concept analysis. Public Health Nursing 21 (2), 144-152