Autonomy in Jeopardy

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

Cath E. Roper; Vrinda Edan


J Participat Med. 2011;3 

In This Article


Contrasting Participatory Health Models With Decision Making Under the MHAV

There is an inherent inconsistency between the basis of participatory medicine and those underpinning MHL. Patient autonomy is assumed in participatory health models characterized by mutually respected expertise where patient empowerment and joint decision making are encouraged.[6] Taking Harris' ethical perspective, being able to make one's own health care decisions is a good thing in itself.[18] Likewise, to be self-determining and free to make choices has independent value and is definitive of personhood and dignity.[19 20 21] Respect for autonomy and self-determination mean that consent to treatment is necessary and people are therefore entitled to know the truth about their medical condition and have the right to accept, withdraw, or refuse treatment. In contrast, the MHAV allows substitute decision making using a "best interests" beneficent approach where treatments are given to patients without their consent. In bioethical terms,[19] the principle of beneficence (doing good) combined with the principle of justice (in this case, the right to access treatment) together provide the rationale for substitute decision making and involuntary treatment — thus outweighing patient decision making autonomy.

Both Australian mental health policy[22 23] and the MHAV[13] emphasize that every effort should be made to involve the person in the development of their treatment plan, in keeping with contemporary ideas about the importance of active patient decision making in health care. Providers are thus placed in ethically ambiguous positions when attempting to fulfill policy and legal directions about encouraging patient involvement in instances where the goal is compliance with mandated treatment to which the patient has not consented. In such cases, the imperative to involve patients in treatment conflicts with the determination that the patient lacks capacity to make decisions.

Topor and colleagues argue that psychiatric services are organized around illness models underpinned by a guiding belief that patients do not know what is in their own best interests.[23] This attitude serves to hamper the establishment of a culture of collaborative partnerships between patients and providers which are gaining credence in other health fields.. However, it could also be argued that MHL itself contributes to the formation of such attitudes since it is invoked precisely because the patient is thought to not know what is in their best interests. Unless these troubling ethical realities of current practice under MHL are faced, focusing on either care models or collaborative approaches will be insufficient to shift such attitudes and beliefs. Rather, the first step is to acknowledge that to be prevented from making treatment decisions has significant ethical consequences. This, together with a belief that one's wellbeing is dependent on being able to make one's own decisions should become the ethic to ground care. Service goals should be focused on creating the conditions that best support patient decision making. In this context, all practices would be directed toward avoiding substitute decision making and involuntary treatment.

Promoting Patient Self-Determination Under MHL

In the case of people subject to MHL, autonomy should be accorded intrinsic and independent value, since it is the ethical principle most at stake. In order to promote patient self-determination and affirm autonomous decision making, new practices are needed. First, capacity would be assumed so that any paternalistic intervention would need to establish which specific decisions were not able to be made and the reasons why. Any departure from respecting patient decision making would need to be considered an aberration rather than a norm. Practice would need to be directed toward facilitation of self-determination and providing opportunities for consent at all times. A transparency around these objectives could form the substance of therapeutic relationships. health care Service quality standards and professional guidelines would need to reflect directives aimed at taking responsibility for creating environments supportive of patient decision making.

Providers would need to clearly understand their roles as substitute decision makers and learn to be transparent about and accountable for the statutory powers conferred on them by the state. For example, Katz proposes restoration of autonomy "prior to the act of healing by not treating patients as children but as adults whose capacity for remaining authors of their own fate can be sustained and nourished.[25]" Similarly, Brody proposes a conversation to determine capacity to consent to treatment.[26] The conversation is designed to encourage participation, render clinical thinking transparent to the patient and tailor information to the individual. The model requires clinical skills such as sharing one's thought processes; encouraging the patient to ask questions; and finding out how much the person wants to participate.