Autonomy and Medical Practice

What is the principle of autonomy and what role does in play in physician-assisted suicide, treatment refusal, and truth telling. Is the decision to receive help dying (prior to the body giving out) an absolute moral consideration -- and what makes the decision a good one? There are many more questions, all of them pertinent, surrounding the assisted suicide issue, and some will be presented and critiqued through the literature available on the topic.

Phillip M. Kleespies has written a book called Life and Death Decisions: Psychological and Ethical Considerations in End-of-Life Care; in his review of the book Dr. Jack Schoenholtz insists that at this time in American history "…we leave the end-of-life decision to personal autonomy" (Schoenholtz, 2004, p. 1936). Schoenholtz reports that this book is mainly for the benefit of psychologists, who should be using their skill "in conflict management, to become important members" of the team that is consulting on a particular person's death desire. Referencing Kleespies, Schoenholtz writes that presently too many psychologists are "locked out" of the team of "core hospice service providers"; Schoenholtz appreciated that portion of the book but he rips into Kleespies (giving readers his own view in the meantime) for not mentioning the "major national initiatives" that are studying the end-of-life milieu.

What Schoenholtz did appreciate in the book -- given that he criticized almost every other chapter in Kleespies' narrative -- was that again, psychologists should have a prominent place in the matter, probably with the hospice professionals.

"Accommodations invariably infringe someone's autonomy," according to essayist Jerome E. Bickenback, and so the issue "is not whether there is infringement" on autonomy, "but whether it is justified" (Bickenback, 1998, p. 129). In Canada, the term "safeguards" in reference to physician-assisted suicide, means that "procedural techniques" are in place to assure that "the potential suicide is competent, has made the decision freely and voluntarily" and that the person is truly terminally ill and in "unrelievable pain" (Bickenback, 130). Moreover, in Canada physician-assisted suicide can only be carried out legally if the person in question "is physically incapable of performing the act of suicide and has adequate opportunity to change his or her mind," which comes back to autonomy. Would it be immoral for the person that meets the criteria mentioned earlier in this paragraph to be denied the right to die? That is a question for the state, the doctors, the families, and the field of psychology.

As for Bickenback, he insists that autonomy should be "preserved" and in fact if a patient has the right to autonomy, "then there is no reason, indeed we have no right, to inquire into the motivation for the decision" (130). The essayist firmly tackles the issue of autonomy again on page 130: "Respecting autonomy does not mean respecting the right of people to arrive at correct decisions that are in their self-interest and consistent with their welfare; it means respecting their right to make whatever decision they wish."

Essayist Francis J. Beckwith puts his views on the line in the first paragraph of his essay; he claims that the "most significant and influential contribution" that bioethicists have made to the issue of physician-assisted suicide is "their affirmation that a fundamental principle of medical ethics is the principle of respect for autonomy (or patient autonomy)" (Beckwith, 1998, p. 223). The principle of autonomy has been pivotal -- according to Beckwith -- in "empowering patients and moving medicine away from physician paternalism" (223).

Beckwith quotes Dr. Jack Kevorkian, who attended a luncheon where Beckwith was present; after the meal there were questions and answers. Kevorkian was asked to articulate his "underlying philosophical belief," and he answered that "…it's quite simple: Absolute personal autonomy. I'm an absolute autonomist. Do and say whatever you want to do and say at any time you want to do or say it, as long as you do not harm or threaten anybody else's person or property" (Beckwith, 223). Many observers see Kevorkianism "as an ethical aberration," Beckwith admits, but there is "reason to believe that absolute autonomy is becoming the primary dogma by which courts, especially the U.S. Supreme Court…" (224). He quotes from the High Court's decision in Planned Parenthood v. Casey: "Our law affords constitutional protection to personal decisions relating to marriage, procreation, family relationships, child rearing… [all of which relate] to personal dignity and autonomy…" (224).

There are other…