Autonomy Health Dictionary

Equipment that enables an individual who requires assistance to perform the daily activities essential to maintain health and autonomy and to live as full a life as possible. Such equipment may include, for example, motorized scooters, walkers, walking sticks, grab rails and tilt-and-lift chairs.... assistive device

The basic evaluative principles which (should) guide “good” care. Principles typically refer to respect for, and the dignity of, human beings. Basic dimensions are “autonomy” (respect for self determination), “well-being” (respect for happiness, health and mental integrity) and “social justice” (justifiable distribution of scarce goods and services). More specifically, ethics of care refer to ethical standards developed for the care professions which are designed to implement ethical principles in the practice of care provision.... ethics (of care)

Broadly, the several neuron masses, ganglia, and nerve fiber plexus that lie in the walls of the intestinal tract, particularly the small intestine. They monitor and stimulate local muscle and glandular functions as well as blood supply, with little interface or control by the central nervous system or the autonomics. Each synapse away from the CNS gives greater autonomy, and these nerves only listen to God ... and food. This means the small intestine is relatively free of stress syndromes.... myenteric plexus

This is de?ned as comprehensive care of patients and families facing terminal illness. The care focuses primarily on comfort and support. Such care includes:

careful control of symptoms, especially PAIN.

psychosocial and spiritual care.

a personalised management plan centred on the patient’s needs and wishes.

care that takes into account the family’s needs and that is carried into the bereavement period.

provision of coordinated services in the home, hospital, day-care centre and other facilities used by the patient. Palliative care should include: managing

chronic cancer pain with planned use of common ANALGESICS including opioids (see SYRINGE DRIVERS); planning ahead to preserve as far as possible the patient’s autonomy and choice as death approaches and the ability to make decisions may decline; and an understanding and use of arti?cial feeding and hydration. Palliative care seeks to improve the satisfaction of both patient and family, to identify their needs and, if possible, to reduce the overall cost because the patient can often be looked after at home or in a HOSPICE instead of in hospital.

A well-publicised question that may arise in the context of palliative care is physician-assisted suicide. This subject is referred to in the entry on ETHICS. A request by a patient for accelerated death may suggest that he or she is depressed – a treatable condition – or that the palliative care is inadequate and needs reviewing and, if possible, improving.... palliative care

The product of the interplay between social, health, economic and environmental conditions which affect human and social development. It is a broad-ranging concept, incorporating a person’s physical health, psychological state, level of independence, social relationships, personal beliefs and relationship to salient features in the environment. As people age, their quality of life is largely determined by their ability to access needed resources and maintain autonomy and independence.... quality of life

n. the stage of development between childhood and adulthood. It begins with the start of *puberty, which in girls is usually at the age of 12–13 years and in boys about 14 years, and usually lasts until 19 years of age. All adolescents must learn gradually to exercise their own *autonomy, whether they have legal *capacity or not. Clinicians may not know who has the *responsibility to take decisions without careful thought and discussion (see also Gillick competence).... adolescence

the most common form of *dementia, occurring in middle age or later. It is characterized by memory impairment and, as the disease progresses, language difficulties, *apraxia, and visuospatial problems, leading to a loss of judgment and the inability to carry out even basic functions. At post mortem there are excess deposits of *amyloid protein and *neurofibrillary tangles in the brain. In rare cases of familial Alzheimer’s, mutations in three genes have so far been detected; patients with these genes usually have early-onset dementia. The cause of the common sporadic form is not known although genetic factors can significantly increase the risk of developing the disease. Mutations in four other genes have been implicated in the more common late-onset form of the disease. The demonstration of damage to the cholinergic pathways has led to the development of *acetylcholinesterase inhibitors, which have been shown to slow disease progression. Ethical problems in the care of someone who has been used to making their own decisions (but now cannot) include respecting what *autonomy remains, how to gain valid *consent for treatment, and how to allow the patient proper *dignity. [A. Alzheimer (1864–1915), German physician]

AMA see American Medical Association.... alzheimer’s disease

n. agreement to undergo medical treatment sought from an adult or child who lacks capacity to *consent. More generally, permission from patients with capacity, but whose autonomy is constrained, given to their doctor to act in their *best interests. Assent has ethical but not legal force. In medical research, particularly with children over seven years, it is difficult to justify proceeding without assent, since research is not principally and inevitably in the patient’s best interests.... assent

n. doing good: one of the *four principles of medical ethics. The obligation to act in patients’ *best interests at all times is recognized in ancient and modern codes of professional conduct, e.g. the *Hippocratic oath. Benefits in health care, and therefore beneficence, must commonly be balanced against risks or harms (i.e. *nonmaleficence). The courts have been clear that beneficence extends beyond medical interests. Respect for *autonomy requires that professionals determine what the patient considers to be doing good in any given situation.... beneficence

Within most cultures, care of the sick is seen as entailing special duties, codi?ed as a set of moral standards governing professional practice. Although these duties have been stated and interpreted in di?ering ways, a common factor is the awareness of an imbalance of power between doctor and patient and an acknowledgement of the vulnerability of the sick person. A function of medical ethics is to counteract this inevitable power imbalance by encouraging doctors to act in the best interests of their patients, refrain from taking advantage of those in their care, and use their skills in a manner which preserves the honour of their profession. It has always been accepted, however, that doctors cannot use their knowledge indiscriminately to ful?l patients’ wishes. The deliberate ending of life, for example, even at a patient’s request, has usually been seen as alien to the shared values inherent in medical ethics. It is, however, symptomatic of changing concepts of ethics and of the growing power of patient choice that legal challenges have been mounted in several countries to the prohibition of EUTHANASIA. Thus ethics can be seen as regulating individual doctor-patient relationships, integrating doctors within a moral community of their professional peers and re?ecting societal demands for change.

Medical ethics are embedded in cultural values which evolve. Acceptance of abortion within well-de?ned legal parameters in some jurisdictions is an example of how society in?uences the way in which perceptions about ethical obligations change. Because they are often linked to the moral views predominating in society, medical ethics cannot be seen as embodying uniform standards independent of cultural context. Some countries which permit capital punishment or female genital mutilation (FGM – see CIRCUMCISION), for example, expect doctors to carry out such procedures. Some doctors would argue that their ethical obligation to minimise pain and suffering obliges them to comply, whereas others would deem their ethical obligations to be the complete opposite. The medical community attempts to address such variations by establish-ing globally applicable ethical principles through debate within bodies such as the World Medical Association (WMA) or World Psychiatric Association (WPA). Norm-setting bodies increasingly re?ect accepted concepts of human rights and patient rights within professional ethical codes.

Practical changes within society may affect the perceived balance of power within the doctor-patient relationship, and therefore have an impact on ethics. In developed societies, for example, patients are increasingly well informed about treatment options: media such as the Internet provide them with access to specialised knowledge. Social measures such as a well-established complaints system, procedures for legal redress, and guarantees of rights such as those set out in the NHS’s Patient’s Charter appear to reduce the perceived imbalance in the relationship. Law as well as ethics emphasises the importance of informed patient consent and the often legally binding nature of informed patient refusal of treatment. Ethics re?ect the changing relationship by emphasising skills such as e?ective communication and generation of mutual trust within a doctor-patient partnership.

A widely known modern code is the WMA’s International Code of Medical Ethics which seeks to provide a modern restatement of the Hippocratic principles.

Traditionally, ethical codes have sought to establish absolutist positions. The WMA code, for example, imposes an apparently absolute duty of con?dentiality which extends beyond the patient’s death. Increasingly, however, ethics are perceived as a tool for making morally appropriate decisions in a sphere where there is rarely one ‘right’ answer. Many factors – such as current emphasis on autonomy and the individual values of patients; awareness of social and cultural diversity; and the phenomenal advance of new technology which has blurred some moral distinctions about what constitutes a ‘person’ – have contributed to the perception that ethical dilemmas have to be resolved on a case-by-case basis.

An approach adopted by American ethicists has been moral analysis of cases using four fundamental principles: autonomy, bene?cence, non-male?cence and justice. The ‘four principles’ provide a useful framework within which ethical dilemmas can be teased out, but they are criticised for their apparent simplicity in the face of complex problems and for the fact that the moral imperatives implicit in each principle often con?ict with some or all of the other three. As with any other approach to problem-solving, the ‘four principles’ require interpretation. Enduring ethical precepts such as the obligation to bene?t patients and avoid harm (bene?cence and non-male?cence) may be differently interpreted in cases where prolongation of life is contrary to a patient’s wishes or where sentience has been irrevocably lost. In such cases, treatment may be seen as constituting a ‘harm’ rather than a ‘bene?t’.

The importance accorded to ethics in daily practice has undergone considerable development in the latter half of the 20th century. From being seen mainly as a set of values passed on from experienced practitioners to their students at the bedside, medical ethics have increasingly become the domain of lawyers, academic philosophers and professional ethicists, although the role of experienced practitioners is still considered central. In the UK, law and medical ethics increasingly interact. Judges resolve cases on the basis of established medical ethical guidance, and new ethical guidance draws in turn on common-law judgements in individual cases. The rapid increase in specialised journals, conferences and postgraduate courses focused on ethics is testimony to the ever-increasing emphasis accorded to this area of study. Multidisciplinary practice has stimulated the growth of the new discipline of ‘health-care ethics’ which seeks to provide uniformity across long-established professional boundaries. The trend is to set common standards for a range of health professionals and others who may have a duty of care, such as hospital chaplains and ancillary workers. Since a primary function of ethics is to ?nd reasonable answers in situations where di?erent interests or priorities con?ict, managers and health-care purchasers are increasingly seen as potential partners in the e?ort to establish a common approach. Widely accepted ethical values are increasingly applied to the previously unacknowledged dilemmas of rationing scarce resources.

In modern debate about ethics, two important trends can be identi?ed. As a result of the increasingly high pro?le accorded to applied ethics, there is a trend for professions not previously subject to widely agreed standards of behaviour to adopt codes of ethical practice. Business ethics or the ethics of management are comparatively new. At the same time, there is some debate about whether professionals, such as doctors, traditionally subject to special ethical duties, should be seen as simply doing a job for payment like any other worker. As some doctors perceive their power and prestige eroded by health-care managers deciding on how and when to ration care and pressure for patients to exercise autonomy about treatment decisions, it is sometimes argued that realistic limits must be set on medical obligations. A logical implication of patient choice and rejection of medical paternalism would appear to be a concomitant reduction in the freedom of doctors to carry out their own ethical obligations. The concept of conscientious objection, incorporated to some extent in law (e.g. in relation to abortion) ensures that doctors are not obliged to act contrary to their own personal or professional values.... ethics

a legal and ethical standard in medical care and treatment. A doctor has both an ethical and a legal obligation to maximize a patient’s welfare or wellbeing. When cases have gone to court, the judiciary has been clear that the concept of best interests extends beyond the purely medical. The principle of *autonomy requires that a patient with *capacity is in the best position to determine what is in his or her best interests. Where a patient lacks capacity, health-care professionals must act in his or her best interests. Under the Mental Capacity Act 2005, a doctor must take account of the patient’s wishes and try to determine what he or she would have wanted, possibly with reference to an advance directive (see advance directive, decision, or statement), an appointed proxy, or an *independent mental capacity advocacy service. The interests of children are especially important, and doctors must be particularly vigilant where there is a potential conflict of interests, as when reporting cases of suspected child abuse or recruiting for paediatric research.... best interests

n. an approach to ethics and politics that advocates a middle way between communism and liberalism, emphasizing family and community interests as well as individual *autonomy, social responsibilities, and personal rights.... communitarianism

a refusal to behave in a socially or legally accepted way because such behaviour is counter to one’s personal beliefs, principles, or values. Conscientious objection is commonly, but not always, based on religious belief. In some areas of medical practice, there is legal provision allowing for conscientious objection; for example, by virtue of the Abortion Act 1967, section 4(1), a doctor can lawfully refuse to perform an abortion on the grounds of a conscientious objection but must refer the patient to a colleague who will carry out the procedure. Adherents of some religious denominations, such as Jehovah’s Witnesses, may refuse life-saving treatments, frequently those involving blood products, on the grounds of conscience and religious belief, and provided the patient has capacity, a doctor is bound to respect the wishes or *autonomy of the patient.... conscientious objection

n. agreement to undergo any medical treatment or to participate in medical research. Three criteria must be met for consent to be legally valid, namely that the patient must: (i) have capacity to make a choice; (ii) be provided with sufficient information (see informed consent) as to the nature of treatment, its likely consequences, and the possible effects of not having treatment; (iii) be in a position to decide voluntarily, i.e. without external pressure or influence, which may entail giving the patient time to consider the options. In addition, the patient should be informed that they can change their mind about treatment at any point. Valid consent usually provides a legal defence against the charge of *battery (trespass against the person). Claims of *negligence may be brought if the doctor discloses insufficient or inadequate information or fails to answer the patient’s questions and address his or her concerns. Consent need not be in writing, but the more invasive the treatment proposed the greater the need for evidence of consent to be recorded. Signed consent forms are commonly used for this purpose, and are legally required when recruiting a subject to a clinical trial. Valid consent is not required in an emergency or where a patient lacks capacity. The concept of *therapeutic privilege formerly provided a further exception to the requirement that patients should give valid consent, but its scope of application is now much more narrowly defined. See also assent; autonomy.... consent

n. the act of deliberately misleading, misrepresenting, or withholding information. Respect for patient *autonomy and the importance of trust in therapeutic relationships require that doctors should always strive to be honest with patients. The use of deception in research (see intervention study) is ethically highly controversial. See also therapeutic privilege; truth-telling.... deception

Do Not Attempt Resuscitation order: an instruction, usually made by a patient while he or she has capacity and recorded in their notes, requesting that doctors desist from performing resuscitation in the event of physiological failure. By respecting a patient’s choice with regard to resuscitation, a doctor is respecting that patient’s *autonomy. If resuscitation is considered *futile, a decision not to attempt it may be taken; ideally, this should be communicated to the patient and the reasons explained sensitively.... dnar order

n. giving or returning power to someone. Being ill is usually experienced as losing the ability to act as one wishes, and full recovery may only be achieved when the individual feels able to make their own decisions. This may be a problem where professionals insist on deciding for patients with certain conditions (e.g. mental illness). Empowerment involves action to redress the lack or *loss, for instance by offering explanation in a language, style, and level that is appropriate. See also autonomy; feminist ethics; paternalism.... empowerment

an approach to medical ethics, proposed by Tom Beauchamp and James F. Childress, that identifies four basic tenets of ethical practice, namely: respect for *autonomy, *beneficence, *nonmaleficence, and *justice. Although the four principles are often used as a framework for decision-making in Western medical ethics, there may be problems when principles conflict or their application is contested in practice.... four principles

approaches to moral questions based on the thought of the German philosopher Immanuel Kant (1724–1804). These seek to discover what is morally right by asking what basic rules all rational people (see autonomy) could adopt for themselves and then act on as an *imperative matter of *duty, regardless of their personal desires or of the possible consequences (see deontology; consequentialism). The Kantian tradition has been influential in medical ethics, especially in its insistence that every human life must be treated as an end in itself and not simply as a means.... kantian ethics

n. (in clinical practice) a patient’s sense that they are respected as an individual and that they are not being exposed unnecessarily or without their agreement to procedures they might find degrading. The preservation of dignity is important whenever people are undressed, asked very personal questions, seen by more than one clinician, discussed in a group in the third person, or involved in activities that are not essential (such as teaching). Clinical failures here may lead to lack of compliance with treatment (see adherence) or even *complaint or depression (because of humiliation and loss of self-worth). Dignity is important when patients have lost abilities or have learning difficulties, and is vital in the care of any client group where help is needed with personal functions or when someone is *dying. See also autonomy.... dignity

the standards of conduct required of medical professionals and also the academic study of ethical issues arising from the practice of medicine. From the *Hippocratic oath onwards, standards are designed to reassure that professionals subscribing to them will act in the *best interests of, and will avoid harming, their patients. Today they lay greater emphasis on patient *autonomy, while the contemporary study of medical ethics is concerned with a great variety of complex societal and social issues related to medical practice and research. Medical ethics is now taught in all medical schools in the UK as an essential part of a professional training, and the wider field of *bioethics is becoming a recognized academic specialty. See also clinical ethics; feminist ethics; public health ethics; publication ethics; virtue ethics.

Guidance on good medical practice from the website of the General Medical Council... medical ethics

legislation for England and Wales, which came into force in October 2007, to govern the treatment of people who lack *capacity to make decisions. It gives legal force to the importance of *autonomy in health care and to *advance directives, decisions, or statements. It also provides statutory legislation for medical and social decision-makers to act in the patient’s best interests should he or she lose capacity (see Independent Mental Capacity Advocate). It allows proportionate force to implement decisions made in a patient’s best interests. For Scotland the current legislation is the Adults with Incapacity (Scotland) Act 2000.... mental capacity act 2005

n. an attitude or policy that overrides a person’s own wishes (*autonomy) in pursuit of his or her *best interests. The classic argument against paternalism of the philosopher John Stuart Mill is that intervention is justified only when trying to prevent a person from causing harm to others, not to himself. However, a form of paternalism may be justified when a person lacks the capacity to make decisions for him- or herself, assuming there is no valid *advance directive, decision, or statement or a proxy with *power of attorney to represent the patient’s wishes. See also therapeutic privilege. —paternalistic adj.... paternalism

n. a medicine that is ineffective but may help to relieve a condition because the patient has faith in its powers. New drugs are tested against placebos in clinical trials: the drug’s effect is compared with the placebo response, which occurs even in the absence of any pharmacologically active substance in the placebo. Use of placebos in treatment is controversial, with some believing that such treatment compromises the patient’s *autonomy and compromises the virtue of honesty, thereby potentially undermining the doctor–patient relationship.... placebo

n. the condition of being apart from public view. The law recognizes privacy as a *human right by virtue of the Human Rights Act 1998, although there are occasions when this right may be overridden (for example, in legal proceedings). In medical ethics, the concept is associated with maintaining a patient’s dignity and *autonomy and with the doctor’s duty of *confidentiality.... privacy

the ethics of population (as opposed to individual) health, including issues related to epidemiology, disease prevention, health promotion, *justice, and *equality. Public health ethics is commonly concerned with the tensions between individual *autonomy and *communitarianism and/or *utilitarianism.... public health ethics

the process of critically considering one’s own professional practice during or after events in order to review one’s values and to understand the emotions and reasons behind one’s actions and decisions and the effect of those actions and decisions on others. Reflection is seen as essential to developing and maintaining ethical medical practice. See autonomy.... reflective practice

n. the prevention of unnecessary *harm to patients, staff, family, and the general public. Where a patient cannot exercise *autonomy, lacks self-control and normal judgement, or has a tendency to become violent, safety may become a key issue in devising a treatment plan. See incompetence; section.... safety

n. telling the facts openly, honestly, and unambiguously. Clinicians should speak truthfully to their patients unless there are acceptable justifications not to do so that respect the patient’s *autonomy. Without knowing what is wrong, for instance, a patient cannot make a choice of treatments or decide whether to be treated at all. Candour or openness is a requirement of *professionalism but does not extend to inappropriate revelations from clinicians about their personal lives. See also therapeutic privilege.... truth-telling

adj. 1. describing a decision or action taken freely, i.e. without coercion or undue pressure. *Consent must be voluntary if it is to be legally valid. See also autonomy. 2. under the control of *striated muscle.... voluntary

n. deliberately causing one’s own death. A distinction is usually drawn between attempted suicide, when death is averted although the person concerned intended to kill himself (or herself), and other forms of *deliberate self-harm, when the harm is inflicted for reasons other than actually killing oneself. Following the Suicide Act 1961, suicide is not a criminal offence in the UK, but it remains a criminal offence for a person to aid, abet, counsel, or procure the suicide of another (see assisted suicide). There is good evidence that asking about suicidal thoughts and especially plans is important in the management of depression: and no mention or attempt should be dismissed without appropriate assessment and help, especially in vulnerable groups, such as teenagers or the isolated elderly. Charities such as Samaritans have a vital role to play. See also autonomy.... suicide

the entitlement of a doctor to withhold information from a patient when it is feared that disclosure could cause immediate and serious harm to the patient (e.g. because he or she is suffering from severe depression). In exceptional cases, the need to withhold information may be considered to override the requirement to obtain informed *consent before proceeding with treatment. In such a case therapeutic privilege could be used as a legal defence against the charge of *battery or *negligence. If doctors are intending to invoke the concept of therapeutic privilege they must be prepared to justify their decision. Furthermore, while it was once quite common for doctors to withhold bad news or upsetting information from patients for *paternalistic motives, it is now considered a breach of the patient’s *autonomy and the ethicolegal justification for invoking therapeutic privilege where a patient has *capacity is, if it exists at all, extremely limited.... therapeutic privilege