Kris English, PhD
Professor Emeritus
The University of Akron
The concept of patient autonomy is a fundamental right in today’s health care system (Bernstein, 2018). Per Walter and Ross (2014), classic textbooks teach us that “autonomy is all about individualism and the rights of patients to make decisions without paternalistic interference” (p. S18). It is such a strongly held concept that, overall, we are likely left with the impression that respect for autonomy apparently “obliges clinicians to tell patients about health care options, then stand back and abide by their choices” (emphasis added)(Enwistle et al., 2010, p. 741).
While protecting and empowering patients, the principle of patient autonomy might give an audiologist pause. When the standard definition of patient autonomy isolates the patient as decision-maker and ignores the influence of the clinician, how do we provide patient-centered care? If we are expected to “stand back and abide,” then PCC conversations such as shared decision-making would be inappropriate. If these two principles — patient autonomy and PCC — are at odds, how do we reconcile the values each principle represents?
A Bright Idea: Expand the Definition
The tension between these two concepts has not gone unnoticed. In the 1980’s, bioethicists saw the need to revisit the narrow “self-sufficient” version of patient autonomy – not to limit patient rights but also to include the clinician. The point was made that “in the clinical setting, perhaps more than in any other, patients are not self-sufficient, and an expanded definition of autonomy is required to preserve their sense of self-governance and the ability to assume the responsibility of making choices” (emphasis added)(Tauber, 2005, p. 123). Incorporating the basic tenets of autonomy within a relational context came to be known as relational autonomy.
Relational Autonomy in Audiology
Mackenzie and Stoljar’s (2000) description of relational autonomy will resonate with audiologists:
Relational autonomy perspectives are premised on a shared conviction that persons are socially embedded and that agents’ identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants, such as race, class, gender, and ethnicity.
And a comparison of clinic variables is certainly consistent with patient-centered audiologic counseling (from Wilson & Ross, 2014):
Treading Carefully
Needless to say, patients vary in their comfort level with autonomy of any kind. Variables include patient education levels, age, the nature of decisions being considered, and the type and severity of health concerns. Cultural differences must also be considered: in many societies, patients and families prefer health care providers to assume a paternal role, and prefer a different balance between personal autonomy and the involvement of the family in decision-making (Tauber, 2005).
So… Can Patient Autonomy and Patient-Centered Care Co-exist?
Yes — as long as we evolve with the field of bioethics.
- We can recognize that the classic definition of patient autonomy serves the patient well but inadvertently (and unhelpfully) overlooks the role and impact of the clinician.
- We can mindfully define ourselves as practitioners of relational autonomy: always honoring patient choice and agency, within a relationship-based context.
And in all likelihood, even though the terminology may not be familiar, audiologists already practice relational autonomy. We already understand how patient choice and agency is integrated into patient-centered care and shared decision making. One indicator: the communication and interpersonal skills involved in relational autonomy are already represented in audiologic counseling.
References
Mackenzie, C, & Stoljar, N. (Eds.).(2000). Relational autonomy: Feminist perspective on autonomy, agency, and the social self. New York, NY: Oxford University Press.
Tauber, A. (2005). Patient autonomy and the ethics of responsibility. Cambridge, MA: MIT Press.