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Paul Wolpe has addressed one of the most disputable issues in bioethics. The researcher argues that autonomy has become a “panacea” in solving ethical issues in the USA (Wolpe 38). The researcher reveals advantages and focuses on the disadvantages of the use of autonomy in the US bioethics. It is important to note that in the USA the principle of autonomy has overweighed the rest of the principles suggested by Beauchamp and Childress (Wolpe 41).
This shift can be explained by some cultural peculiarities of Americans. However, it is also necessary to note that this shift in priorities has proved to be misleading (Gert et al. 109). The principle of autonomy is characterized by far too many restrictions and limitations (Wolpe 55). Therefore, it can hardly be applicable in most cases. More so, it is possible to state that it has become a detriment to patient care as patients are often unwilling and incapable of making decisions that could be made only by physicians on the basis of thorough research which is backed up by the physicians’ experience.
Reasons for the Shift of Priorities
Principlism was articulated by Beauchamp and Childress in the late 1970s (Wolpe 41). The researchers revealed four basic principles which were to become the universal guidance for physicians. The researchers pointed out the principles of “autonomy, nonmaleficence, beneficence, and justice” (Wolpe 41). Notably, in the first part of the twentieth century, the medical practice was dominated by principles of nonmaleficence and beneficence.
However, in the middle of the twentieth century, the shift in priorities took place in the United States. Wolpe notes that people “could easily write a modern history of America by tracing the theme of individual liberty” which is “a long-standing and mythologized American value” (Wolpe 53). Admittedly, individual liberty is valued in any aspect of private or social life in the United States, be it politics, education, or medical care. Of course, bioethics could be no exception. Americans have always struggled for their rights, e.g. rights concerning abortion or even assisted suicide. The value of individual liberty has spread to the power of decision making.
Apart from this, Wolpe articulates another possible reason for the shift. The researcher claims that almost “every development in medicine in the post-World War II period distanced the physician and the hospital from the patient and the community” (Wolpe 50).
The researcher comments upon financial differences between physicians and patients. Admittedly, physicians and patients often pertain to different social classes or ethnic groups, etc. This contributes to alienation which in turn leads to bureaucracy in medical care. Highly bureaucratic practices can also be regarded as some of the factors that have led to a shift in priorities. Thus, instead of making decisions physicians are overwhelmed by various bureaucratic practices that should be complied with. These bureaucratic practices also become certain standards accepted by patients.
Many researchers state that the principle of autonomy is the most applicable in real-life settings as it is the most “constitutive” (Engelhardt 107). Engelhardt also claims that it is rather difficult to be objective when it comes to other principles whereas the principle of autonomy can be easy to realize (107). The researcher also argues that the principles are often incompatible. However, the principle of permission (which is another term for the principle of autonomy) can be combined with other principles, e.g. the principle of beneficence (Engelhardt 126).
The principle of autonomy is regarded as a universal principle that can help in any situation. Physicians have particular rules to follow (the rules based on the principle of autonomy) and these rules are accepted by patients. Therefore, the principle suits contemporary medical practice.
However, it is necessary to note that the major reason for the shift in priorities is still the cultural peculiarities of Americans who value individual liberty in every aspect of their lives. Many Americans believe they should have the right to make decisions which can be crucial. Many think that it is their basic right to know the truth and be able to make the necessary decision. Of course, these people disregard many important issues as they are more concerned with their liberties rather than with reasonable and thoughtful decisions. Luckily, at present principlism is being criticized by many. This criticism can become beneficial for the field of bioethics.
Is Autonomy a Detriment or Enhancement of Patient Care?
Admittedly, there are some advantages to the use of the principle of autonomy. For instance, sometimes patients should know the truth. This knowledge can help patients and physicians to make the most acceptable decision for the latter. However, it is also necessary to state that these cases should be regarded as an exclusion rather than a norm. Any other advantages of the use of the principle can hardly be found.
On the contrary, as far as disadvantages are concerned, there are quite many significant drawbacks which can even jeopardize the effectiveness of medical practices. In the first place, as has been mentioned above patients are often unable to make difficult decisions (Wolpe 55). In the majority of cases, patients feel anxiety and stress. They are often incapable of thinking critically. Besides, various diseases affect the way people perceive reality. This factor should also be taken into account as many patients’ decisions should be called into question.
Wolpe also reveals one of the most important factors that confirm that the use of the principle is rather a detriment than a kind of enhancement inpatient care. The researcher claims that
physicians remain the gatekeepers to most medical information in any particular clinical situation and filter that information through their own biases in any presentation of options and risks. (Wolpe 54)
The researcher sheds light upon one of the most conspicuous flaws in the use of the principle of autonomy as there is no complete autonomy. In the first place, the patient is never provided with the complete picture. The data obtained is nothing more than a decision made by the physicians. Thus, the physicians decided on the type of test to carry out, the physician is the one to diagnose, the physician also provides options to be considered by the patient. Admittedly, the patient is never fully informed as the information he/she obtains is based on the knowledge and experience of the physician.
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Apart from this, even if the physician gives comprehensive information, the patient is hardly able to make the right decision. Even if the physician explains all possible outcomes of this or that decision, the patient does not have the necessary knowledge and experience to analyze the situation properly. Thus, it is possible to note that the so-called principle of autonomy presupposes a great deal of dependence as the patient has to rely on the physician’s ability to diagnose as well as reveal specific information.
However, this dependence is not confined to the patient’s lack of knowledge. Some researchers also mention one precondition which can secure the right use of the principle. Wolpe sheds light upon the theory that patients should be matched with the physicians as the two parties should have similar backgrounds (55). In this way, physicians can be able to understand real needs of their patients. This can enable physicians to understand what can be right for the patient and what options can be suggested.
Besides, Wolpe points out that medical care in the United States has become too ‘commercialized’. This sector can easily be compared to the business sector as patient care ceased to be the primary concern of hospitals which are managed as any other business. Hospitals can be compared to numerous enterprises which are run in accordance with particular regulations and standards. However, patient care can hardly be standardized as there are far too many cases (or even the majority of cases) which are not ordinary and need specific decisions. Remarkably, the use of the principle of autonomy helps to fully standardize the system. Thus, physicians do not need to seek for the best and winning decisions as it is enough to obtain the patient’s consent.
The use of the principle should be regarded as a detriment. It is possible to regard the use of the principle as a way to relieve physicians of responsibility. Physicians are not responsible for outcomes of their decisions. They suggest some options and it is the patient who should take the responsibility for his/her life. This can eventually lead to really negative outcomes. Physicians can be inclined to seek for fewer options as they will not feel the responsibility for their mistakes. Admittedly, if a decision is really difficult to make, the physician would rather double-check before he/she makes the decision.
Finally, Wolpe also mentions that many Americans have different backgrounds and not all those addressing physicians are able to make any decision due to cultural peculiarities (55). Physicians should pay a lot of attention to the fact that
significant ethnic and religious subpopulations of the United States do not share a fetish for individualized autonomous decision making, believing instead in the primacy of the family in making important medical decisions. (Wolpe 55)
Admittedly, it is important to respect these people and their values as well. It is clear that there are quite many limitations to the use of the principle of autonomy. Therefore, the principle of autonomy cannot be regarded as prior to the other three principles.
Thus, it is possible to conclude that the four principles articulated by Beauchamp and Childress should be equally important. At least, the principle of autonomy cannot be regarded as the most important one. There are far too many disadvantages in reliance on this principle. This can even lead to various negative outcomes and decrease in quality of patient care. Such significant faults as the lack of knowledge or experience on the part of the patient can lead to numerous wrong decisions. More so, physicians can also tend to seek for fewer options as they can be relieved of responsibility. Admittedly, physicians should not be concerned with papers signed by the patient. Instead, physicians should be concerned with the principles of nonmaleficence and beneficence as their primary role is to heal.
Engelhardt, Hugo Tristram. The Foundation of Bioethics. New York: Oxford University Press, 1996. Print.
Gert, Bernard, Charles M. Culver, and K. Danner Clouser. Bioethics: A Systematic Approach. New York: Oxford University Press, 2006. Print.
Wolpe, Paul Root. “The Triumph of Autonomy in American Bioethics: A Sociological View.” Bioethics and Society: Constructing the Ethical Enterprise. Ed. Raymond DeVries and Janardian Subedi. Upper Saddle River, NJ: Prentice Hall, 1998. 38-59. Print.