Wednesday, September 28, 2011


In an intractable dispute over care at the end of life, should respect for autonomy dictate how to proceed?

Clearly, as the Community Ethics Committee studies medical futility, one thing we’ll need to consider carefully is the value placed on patient autonomy.

I find this passage from Atul Gawande’s book “Complications” insightful:

“Where many ethicists go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it is one value among others. Schneider found that what patients want most from doctors isn’t autonomy per se; it’s competence and kindness. Now, kindness will often involve respecting patients’ autonomy, assuring that they have control over vital decisions. But it may also mean taking on burdensome decisions when patients don’t want to make them, or guiding patients in the right direction when they do. Even when patients do want to make their own decisions, there are times when the compassionate thing to do is to press hard: to steer them to accept an operation or treatment that they fear, or forgo one that they’d pinned their hopes on. Many ethicists find this line of reasoning disturbing, and medicine will continue to struggle with how patients and doctors ought to make decisions. But, as the field grows ever more complex and technological, the real task isn’t to banish paternalism; the real task is to preserve kindness.”

(The Schneider reference is to Carl Schneider, professor of law and medicine at University of Michigan and author of “The Practice of Autonomy.”)

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