Physician Autonomy

RECENT LOCAL GOVERNMENT DECISIONS have increased the risks to community health and safety, sometimes by ignoring medical advice.

Decisions to have or not have an autopsy have impeded crime investigations and violated the standards of forensic pathology, thereby endangering public health and public safety.

Decisions on managing mentally ill adults in jails and other correctional facilities have violated psychiatric standards for diagnosis and treatment, thereby creating an environment that increases the risk of suicide and assault.

Decisions to hold mentally ill and emotionally disturbed youths at juvenile correctional facilities longer than clinically necessary and in less than therapeutic environments have increased the risk of harm to residents and caregivers and of over-charging taxpayers.

At meetings where these issues arose, physicians sounded wounded and angry. They should be. More important, though, is that the public and the caregivers and custodial personnel are endangered.

No one has absolute autonomy, and no one should have. Physicians should be clear about the scope and limits of their autonomy and include competent and responsible others in the decision-making.

Contracts or agreements by which physicians provide medical services should clearly state each party's responsibilities and limits and ensure unfettered authority to fulfill the assigned responsibilities. Contracts or agreements should contain a clear mechanism for resolving disputes.

Patient autonomy requires the patient to be competent to decide and to maintain the decision at least until the procedure is done. That means the patient must know, understand and be free to use information about the medical condition, its prognosis with this or other treatments or without treatment, and the probabilities of success, complications and side effects.

Ultimately the conscious, voluntary patient always exercises autonomy — by complying, rejecting or modifying the recommendations. The patient who does not fill the prescription, or fills it but takes it incorrectly, exercises final autonomy.

Physicians must help patients understand the information, the concept of probabilities, and the recommendations. To do that effectively, physicians must understand what the patient is asking and weighing, not only the medical facts.

Physician autonomy is limited by technical competence and society's sanctions. The physician should reflect an accepting understanding of those limits.

Fragmented communities, diverse values and rapid social and technical changes have eroded public trust in the certainty of knowledge and the authority of authorities. Physicians better expect more challenges to their autonomy.

That is especially true when parties to the decision have conflicting responsibilities. The physician's primary responsibility is to serve the best interests of the patient. The health care or physician group manager's primary responsibility is to ensure the economic survival of the plan or group. The government administrator's primary responsibility is to maintain compliance with public policy.

When missions conflict, as may be likely, there must be clear rules for resolving the conflict. The parties must be free to negotiate the least harmful, most beneficial, trade-offs.

That requires equality and mutual respect. Domination by any participant is coercive, a violation of autonomy and a barrier to the authority needed to fulfill the ethical responsibilities of each party.

Authority, responsibility and autonomy are not synonymous. Physicians want their authority and responsibility respected. In return, they need to respect the authority of those with responsibility for protecting cost and complying with policy.

Physicians must respect the authority and responsibility of law enforcement, corrections, education and social services even as physicians hope those people will respect physician authority and responsibility.

That is the only way that each can arrive at the autonomy that does not trespass on the autonomy of the other.

A good start is to get the contract clear, and to monitor and keep it clear.

Whining won't do it.

edrudin@aol.com