Ethics is a key part of medicine, and those who study and practice medicine are taught and expected to abide by ethical standards that relate to the real world, as well as to key principles within their profession. There are four key principles: autonomy, beneficence, non-maleficence, and justice.
Autonomy is about free will in making informed and independent medical decisions. To be able to exercise this, a person must have capacity (the explicit ability to receive information, understand it, and utilize it to make a decision that they can communicate) and must receive adequate information necessary to make an informed decision.
Beneficence ensures that health workers always act in the patient’s best interests. Non-maleficence emphasizes the Latin phrase “Primum non nocere,” i.e., the principle of “first, not harm.” Justice requires that we treat all people fairly and distribute medical resources equitably.
Of these, autonomy is my favorite principle—not because it is the one I adhere to above the others, but because it is the one I find most nuanced and convoluted in practice.
The Universal Declaration of Human Rights (UDHR), in its first article, states that all humans are born free and equal in dignity and rights. Article 3 speaks to the right to life and liberty; Article 18 to freedom of thought and conscience; and Article 19 to opinion and expression. It further states in Article 25 that everyone has the right to a standard of living adequate for their health and well-being and that of their family. In summary, everyone has the right to the highest attainable quality of health and well-being, but in the process of seeking its provision, they must remain free and informed in choosing how they would like to receive this care, provided it does not infringe on the rights of others or the law. Hence, autonomy.
Why is autonomy interesting?
Medicine has a long history of paternalism, where medical decisions were outsourced by those seeking care to health professionals, and, in turn, professionals developed an inclination to do so—sometimes with little or no reference to the affected individual. There is an apparent “god complex” that seems to afflict health workers, but this is often an outcome of systemic flaws rather than individual attitudes. Healthcare systems favor certain ways of doing things aimed at standardizing care, ensuring patient safety, improving outcomes, and reducing legal liability.
However, strict insistence on clinical protocols and guidelines, hierarchies in rank, responsiveness to time pressures (particularly in critical care and emergencies), and limited resources often result in conflict where the interests of the institution are at odds with those of the individual patient. For example, a patient may consent to a high-risk surgical procedure but refuse a blood transfusion. Autonomy is key here, yet institutional procedures and clinical judgment may disagree.
At the outset, a patient may know little about their medical condition or the dynamics of treatment, creating a degree of information asymmetry. The role of the healthcare provider in this case is not to have the patient defer decisions to them; rather, it is to act as a facilitator or partner, ensuring that the patient has sufficient and relevant information to make decisions appropriate to their circumstances. This reduces information asymmetry and allows doctors to support the patient in decision-making rather than deciding on their behalf.
Notwithstanding this, allowing a patient, or a guardian acting for a minor, to make decisions is limited by what the law permits. The Children’s Act in Kenya, for example, ensures that guardians act in the best interests of minors and provides recourse for health workers should guardians act contrary to this obligation. Similarly, certain interventions may be legally restricted in specific jurisdictions, such as medical abortions, physician-assisted suicide, virginity testing, or the use of unproven therapies. Therefore, while autonomy should be respected, the health worker must recognize legal boundaries and seek conciliatory outcomes that do not isolate the patient or dismiss their request outright.
Autonomy is a good thing. It supports the patient and allows the doctor to practice in an ethically sound manner, often resulting in the best possible outcomes. It frees the doctor from decisions biased by personal values, discourages a one-size-fits-all approach, and, crucially, helps clinicians recognize their limitations.
In the same way, it helps patients receive treatment that makes sense for them based on their circumstances, values, preferences, and resources, and increases the likelihood that they will complete or adhere to a treatment plan.
While it is undoubtedly difficult to ensure autonomy for all patients in all circumstances, the priority remains ensuring that health workers understand the value of encouraging autonomy in practice, as good health outcomes depend on it.
In a subsequent article, we will explore what happens in situations where capacity is impaired, and care becomes involuntary.