Autonomy, coming from the Greek autos (self) and nomos (law), refers to governance over the self. The most basic, and perhaps most important level of professional autonomy for a physician occurs within the self and involves judgment and accountability. Physicians engage in ethical decision-making when they make the judgment: What should be done? Further, physicians must address self-accountability by answering the question: Should I do it? Beyond the individual physician, professional autonomy also involves accountability to one’s peers as well as the public, especially patients.
Judgment: What Should Be Done?
In answering this question, a physician makes a judgment about a specific patient’s care, based especially on the core principles of doing good and avoiding harm. In applying knowledge and experience to a specific patient situation, a physician makes an ethical judgment. For instance, asking if an appendectomy treats appendicitis is an academic question. Asking if Ms. Jones should have an appendectomy becomes an ethical question. By asking this question, we recognize that we are stewards of the tools of our profession, whether we are pediatricians, family medicine doctors, neurosurgeons, or pathologists. As such, we move the question to a moral consideration when we apply it to a specific patient. In making a judgment about prescribing a treatment for a specific patient, we are engaging in ethical decision-making. Because we have professed publicly to heal and not to harm, and because we balance these factors for each patient, all of our recommendations carry moral weight.
Accountability: Should I Do It?
Once we answer “Should it be done?” we must next ask “Should I do it?” In addition to accountability for the judgment itself, this question has two other aspects. The first is, based on my assessment of my skills and abilities, am I the right person to implement this treatment or perform this procedure? This reflects the Hippocratic requirement that one practice according to one’s skill and ability. Answering this requires humility, insight, and reflection. There may be forces that expect you to perform a procedure or treat certain conditions, even if you do not feel qualified. It can take a lot of moral courage to admit that you are not the right person, particularly if there are financial pressures or potential conflicts of interest. In the final analysis, determining your own level of skill and ability in treating a patient is a function of your conscience, over which you have full possession and responsibility.
The other aspect of “Should I do it?” is accountability to your own personal morals. This is often called provider conscience. It is evoked in circumstances in which although it may be ethical for a patient to have a certain procedure or receive a treatment, your own morals do not allow you to participate in the treatment. An example is a patient who requests an abortion. While it may be ethical for the patient to undergo the procedure, your own religious morals may prohibit you from performing it. It is generally recognized that physicians can as a matter of personal morality decline to participate in certain treatments or procedures. However, the ethical obligation to prevent harm to the patient supersedes the physician’s personal morals. As such, circumstances in which there may be a conflict, particularly emergencies, should be anticipated to make sure patients are never harmed.
Professional Autonomy: Peers
The community of peers plays three broad roles in professional autonomy, all seeking to ensure that patients are helped and not harmed. The first is establishing training and credentialing standards for the profession. These can be broad and applicable to the profession of medicine in general and also very specific, applying to subspecialties. There can be requirements for training, examination, proctorship, and maintenance of certification.
The second is establishing practice standards that can be applied to individual patients. These are often evidence based and evolving.
The third function peers serve in professional autonomy is that of retrospective review. Morbidity and mortality conferences, peer review and quality assurance processes all serve to retrospectively ask if the treatment or procedure should have been performed. Although these avenues are typically only invoked when there is a question of whether a patient was harmed, typically in the form of an adverse outcome, there is a clear role for asking also if a patient was helped, even if the outcome was not unfavorable. For instance, it is important to also ask our peers whether, even though the patient did not suffer a complication after a procedure, was she helped by it?
Professional Autonomy – Public
The public, especially patients, have a clear interest in assuring that physicians practice according to the ethical standards that we profess. Government regulation of medical licensing and investigation of patient complaints are common ways this obligation is fulfilled. Increasingly, there are legislative initiatives that seek to answer the question of “What should be done?” rather than allowing physicians, in conjunction with their patients, to answer this. There is debate whether this is a proper function of legislation.
Conflicts Between Patient and Provider Autonomy
Professional autonomy can at times conflict with patient autonomy. This can be a significant source of distress for everyone involved in the patient’s care. Consider the case of Tinslee Lewis, an 11-month-old in Fort Worth, Texas, who was born with a rare heart defect (Ebstein’s anomaly). Despite attempts to save her life, physicians have decided that the condition is irreversible and that she is suffering. They have recommended that she be disconnected from all life-sustaining treatments, but her mother opposes their decision. Her mother believes that she has the duty and right to decide on behalf of her daughter, not the physicians caring for her. The physicians, exercising professional autonomy, believe that Tinslee is being harmed and not helped, and thus do not believe that she should continue to receive life-sustaining treatments. Her mother believes that as the surrogate decision-maker for Tinslee, she has the right to make decisions on behalf of her daughter.
In cases like this where it is difficult to assign one ethical claim priority over the other, it is important to get expert input in order to sort through the issues. In this particular case, the claim of the mother to be the legitimate representative for her daughter is at odds with the claim of the physicians that their treatments are no longer beneficial. While the moral weight of any one claim may not be greater than the other, the claim that harm is being done to the patient and thus causing suffering without apparent benefit, must be seriously considered. In these instances, consultation with a bioethicist would be very important for sorting through the claims. An essential part is also communication and negotiation, particularly if the relationships are strained. Sometimes, after all other avenues have been exhausted, these conflicts require adjudication by the court system.