PATIENT AUTONOMY AND RIGHT

I Nyoman Mangku Karmaya

The Doctor-Patient Relationship

1. this relationship is not only professional but also human

2. it is decisive for the dignity of each3. it develops in the hope to be able to cure and be

cured4. it needs empathy, trust, compassion and

sensitivity5. it is unequal in professional terms but not in

human ones

The Nazi’s Doctor Experiments(research scandal/unethical)

• Twenty doctors revealed evidence of sadistic human experiments

• Conducted at the Dachau, Buchenwald and Sachenschausen concetration camps by murdering and torturing the patient in the name of research

The brutal medical experimentsCharacterized by several shocking features: • (1) persons were forced to become subjects

in very dangerous studies against their will; • (2) nearly all subjects endured incredible

suffering, mutilation, and indescribable pain; and

• (3) the experiments often were deliberately designed to terminate in a fatal outcome for their victims

• (4) the experiments resulted in death, disfigurement, or permanent disability

Basic value in medical practice

• Respect for person/autonomy

• Beneficence• Non-maleficence

• Justice

What is

Autonomy

Definition

• The right of patients to make decisions about their medical care without their health care provider trying to influence the decision.

• Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.

Definition

• Autonomy is the “personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice.” 

• Autonomous individuals act intentionally, with understanding, and without controlling influences.

Clinical Applications:• Respect for autonomy is one of the fundamental

guidelines of clinical ethics. • Autonomy in medicine is not simply allowing patients to

make their own decisions. • Physicians have an obligation to create the conditions

necessary for autonomous choice in others. • For a physician, respect for autonomy includes

respecting an individual’s right to self-determination as well as creating the conditions necessary for autonomous choice. 

Clinical Applications:• Individuals come to doctors for guidance in making

choices because they do not have the necessary background or information for making informed choices.

• Physicians educate patients so that they understand the situation adequately.

• They calm emotions and address fears that interfere with a patient’s ability to make decisions.

• They counsel patients when their choices seem to be disruptive to health and well-being. 

Clinical Applications:

• Respect for autonomy also includes:– confidentiality, – seeking consent for medical treatment and

procedures, – disclosing information about their medical

condition to patients, – and maintaining privacy.

Autonomy• Autonomy = the capacity to think, decide and act

on the basis of such thought and decision freely and independently

• Freedom from the interference of others• This freedom is protected by the law• Legal right to refuse any treatment (even life-

saving)/doing the best for the patient• Conflict between principle of respect for patient

autonomy and principle of beneficence

Autonomy

• Criticize medical paternalism• Development of “patient centred” medicine• Inreasing standards in providing patients

with information• Development of informed consent

The analysis of autonomy• Evaluations

– What kind of life we think we should live/we think might be best for us

• Evaluations should be rational– Based on correct understanding of the relevant facts– Without making a relevant error of logic– Able to imagine what the relevant state of affairs will

be like– Respecting a person’s autonomy is not always be the

same as respecting her choice• Desires higher in the hierarchy should be

respected

Delegate the choice

• The choice is burdensome• Not very good in choosing for herself• Usually enjoys going alongwith the choices of

her friends======================================• Ask for the doctor to choose = autonomously:

– He trust the doctor’s judgement– Making choice is difficult– Believes with the doctor’s experiences

Right

• Patient rights encompass legal and ethical issues in the provider-patient relationship:– right to privacy– right to quality medical care without prejudice– right to make informed decisions about care

and treatment options– right to refuse treatment

The purpose

• to ensure the ethical treatment of persons receiving medical or other professional health care services– a person's ability to sue a health plan provider;– access to emergency and specialty care, – diagnostic testing, – prescription medication without prejudice;– confidentiality and protection of patient medical

information;– continuity of care.

The basic rights include the right to:

• participate in the development and implementation in the plan of care

• be treated with respect and dignity • be informed about condition, treatment options, and the

possible results and side effects of treatment • refuse treatment in accordance with the law, and receive

information about the consequences of refusal • quality health care without discrimination because of

race, creed, gender, religion, national origin, or source of payment

• privacy and confidentiality, which includes access to medical records upon request

The basic rights include the right to:

• personal safety • know the identity of the person treating the patient, as

well as any relationship between professionals and agencies involved in the treatment

• informed consent for all procedures • information, including the medical records by the patient

or by the patient's legally authorized representative and hospital charges, except for Medicaid and general assistance

• consultation and communication • complain or compliment without the fear of retaliation or

compromise of access or quality of care

Hak pasien (Deklarasi Lisabon 1991)

• Hak memilih dokter• Hak dirawat dokter yang “bebas”• Hak menerima/menolak pengobatan

setelah menerima informasi• Hak atas kerahasiaan• Hak mati secara bermartabat• Hak mendapatkan dukungan

moral/spiritual

Hak pasien (UU Kesehatan)

• Hak atas informasi• Hak atas second opinion• Hak memberi persetujuan

pengobatan/tindakan medis• Hak atas kerahasiaan• Hak pelayanan kesehatan

Recommendations for Enhancing Patient Autonomy

• Share your medical expertise fully while listening carefully to the patient's perspective.

• Recommendations must consider both clinical facts and personal experience

• Focus first on general goals, not technical options

• Disagreements should initiate a process of mutual exchange

• Final choices belong to fully informed patients

TERIMAKASIH