Autonomy in Jeopardy

Contrasting Participatory Health Models With Patient Decision Making Under Mental Health Law

Cath E. Roper; Vrinda Edan

Disclosures

J Participat Med. 2011;3 

In This Article

Abstract and Introduction

Abstract

Respect for patient autonomy is fundamental to participatory health models where treatment decisions are made through a partnership based on mutually acknowledged expertise between patient and provider. For patients subject to mental health law (MHL), however, patient autonomy can be overridden on grounds of incapacity to make treatment decisions. In such cases, providers become substitute decision makers and patients may be treated without their consent, presenting a challenge for participatory practices. This paper uses an ethical lens to focus on limits placed on health care decision making in the case of people governed by MHL, using Victoria, Australia as its example. It is argued that the first step must be to recognize loss of patient autonomy under MHL as an ethical problem worthy of attention. Only then can the impact this may have on patients and providers alike be appreciated and faced, and ethically grounded practices affirming patient autonomy, consent, and voluntariness be developed.

Introduction

Evidence of the benefits of patient involvement in health care decisions and management of health conditions has resulted in patient participation becoming a cornerstone of contemporary health care policy and practice.[1 2] Practitioners are expected to provide information to patients and lay out the risks and benefits of various treatments, so that patients can make informed decisions that suit their values, lifestyles, and preferences.[3] One widely known participatory health model is shared decision making, described as "a process by which a health care choice is made jointly by the practitioner and the patient.[4]" Such characterizations of the modern health care relationship assume autonomous decision making on the part of patients. Increasingly, expectations of patient-provider relationships are moving beyond patient involvement in decision making to partnerships in which the patient is an active, empowered, and equal member, and the expertise each participant brings to the medical encounter is mutually respected and valued. This type of partnership relies on a context of power sharing, relationship, and patient autonomy, and a power shift away from medical paternalism towards open negotiation.[5 6]

Expectations of health partnerships in which providers encourage patient participation in care have been carried over into mental health policy and law, but do not directly address the consequences and ethical significance of loss of patient autonomy to make health care decisions. The overlay of participatory frameworks onto mental health policy and law serves to mask significant ethical issues at stake for patients who are governed by MHL, where patients are not free to make autonomous health care decisions in a voluntary context. Providers may be placed in ethically challenging positions, attempting to establish partnerships and encourage patient participation on the one hand, yet working with a mandated treatment plan that the patient may not have agreed to, on the other.

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