1Patient Autonomy

RUNNING HEAD: PATIENT AUTONOMY

Patient Autonomy: A Concept Analysis

Dallas Dooley and Susan Swords

NU 500 Theoretical Foundations of Advanced Nursing Practice

December 7, 2011

2Patient Autonomy

Patient Autonomy: A Concept Analysis

Introduction

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.

Definition

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).

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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

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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

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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.

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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

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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.

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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

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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.

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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

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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.

Defining attributes

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

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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.

Model Case

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.

Antecedents

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.

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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.

Consequences

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

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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.

Empirical Indicators

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.

Recommendations

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.

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References

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:

10.1891/1073-7472.14.1.1

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

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Figure 1

Literature Review key

terms on patient autonomy

LEGAL

14th AmendmentPhysician Assisted

SuicideFreedom of Choice

CULTURAL

Cultural CompetencyDiversity

Effective DeliberationCultural Authenticity

PHILOSOPHY

Self-readingSelf-

ConceptualizationSelf-RecognitionSelf-Definition

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Figure 2

Patient Autonomy

Patient Autonomy

Antecedents Self-reading and recognition Variable Internal and External Factors Self-confidence and Self-esteem Perception of their illness Willingness and ability to make choices Family Communication/Orientation Trust in the nursing staff

Consequences Personal Satisfaction Freedom Reassurance of self Enhanced life-style and

quality of life Better nurse-patient

relationship Increased

Productivity Negative Outcomes

Contributing Factors Legal Aspects Patient’s philosophy Culture Education Motivation

Empirical Indicators Take steps to ensure patients

able to make sound decisions Observation of patient behaviors Complete the autonomy

questionnaire Assist patient in receiving as

much information as possible

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Figure 3

Autonomy Questionnaire

1. Is the patient alert and oriented? Yes No2. Does the patient have an altered level of consciousness? Yes No3. Is the patient free from outside influences? Yes No4. Is the patient making this decision voluntarily? Yes No5. Has the patient been fully informed prior to making the decision? Yes No6. Is the patient taking an active role in their care? Yes No7. Does the patient have a high self-esteem? Yes No8. Does the patient have an accurate opinion of their illness? Yes No9. Is there a good provider-patient relationship? Yes No10. Is the patient at their appropriate developmental level? Yes No

If any answers are ‘No’, the patient may not be able to make an autonomous decision without further intervention.