The Practice of Autonomy: Patients, Doctors, and Medical Decisions - Hardcover

Schneider, Carl E.

Hardcover

ISBN 10: 0195113977 ISBN 13: 9780195113976

Publisher: Oxford University Press, 1998

Synopsis

This is a book written across the grain of contemporary ethics, where the principle of autonomy has triumphed.It is an attempt to see the law of medicine, the principles of bioethics, and the encounter between doctor and patient from the patient's point of view. While Schneider agrees that many patients now want to make their own medical decisions, and virtually all want to be treated with dignity and solicitude, he argues that most do not want to assume the full burden of decision-making that some bioethicists and lawyers have thrust upon them. What patients want, according to Schneider, is more ambiguous, complicated, and ambivalent than being "empowered." In this book he tries to chart that ambiguity, to take the autonomy paradigm past current pieties into the uncertain realities of modern medicine.

About this title

About the Author

Carl E. Schneider is at University of Michigan.

Reviews

The process of making medical decisions in the United States today is, in theory, a neat and well-defined affair. Authority and responsibility are shared, as mentally and emotionally capable adults choose voluntarily and intelligently from among various options whose relative risks and benefits their personal physicians have fully explained to them. Gone are the days of medical paternalism, when arrogant health care professionals misused their power to force particular treatments on dependent patients who blindly trusted them. In place of that trust -- and good riddance -- bioethicists and health care lawyers have, over the past three decades, substituted the ritual of informed consent. The only question remaining is whether all patients should always be compelled to make each decision about their health care (mandatory autonomy) or whether on some occasions we ought to recognize a patient's prerogative thoughtfully and explicitly to waive personal control and delegate that authority to others, including the physician.

The problem, of course, is that in practice, the exercise of autonomy in the medical context is frequently rather messier and more complicated than the prevailing bioethical theory and law would have us believe. Every physician who cares for patients knows this, and University of Michigan law professor Carl Schneider explicates this reality cogently in the most comprehensive, organized summary and analysis to date of the quantitative and qualitative empirical research on the actual process of medical decision making. Complemented by a thorough examination of the voluminous literature of memoirs by former patients and by Schneider's own studies of patients with renal disorders, the result is a scholarly, insightful rejection of the contemporary bioethical wisdom that the making of complex medical decisions can be reduced to a single, uniform, legally enforceable model.

In place of the current emphasis on maximizing patients' autonomy by ensuring their independence from others, Schneider urges as the ideal an optimizing of their autonomy. Optimal, rather than maximal, involvement of patients in decision making would take into consideration particular variables pertaining to the patient (e.g., the existence of intimate relationships that the patient might wish to rely on instead of exercising his or her independence) and to the medical context (e.g., whether the choice that the patient faces is chiefly technical or value-laden, whether it is reversible or permanent, and whether it will be made once or repeatedly).

According to Schneider, however, even this ideal of fashioning informed consent to conform to the individual patient and the particular context of his or her life will be essentially unattainable in an increasingly bureaucratized health care marketplace in which the locus of decision making moves steadily away from both patient and physician, toward faceless third parties. Thus, Schneider ultimately calls for less emphasis on the process of medical decision making (the due-process approach of informed-consent doctrine that frequently results in empty rather than meaningful consent) in favor of a bioethical perspective that focuses on the results of that process. "Perhaps," he suggests, "we should redirect our attention away from the procedures by which medical decisions are made and toward their substance.... One alternative is to look directly at those decisions and try to improve them.... It may be more fruitful to change what medicine does rather than to increase patients' autonomy." In place of the current consumer-choice model, he proffers detailed advice on how to begin to achieve the two aspects of the consumer-welfare model that he thinks most people would prefer -- namely, competence and kindness.

Schneider supports the principle of patient autonomy. But at the same time, he effectively deflates its most unrealistic, and arguably undesirable, pretensions. He sums up his work by observing that "informing our bioethical thinking with an understanding of how the world works will richly reward the effort." His intended audience of physicians, bioethicists, attorneys, and social scientists should agree strongly with this assessment.

Reviewed by Marshall B. Kapp, J.D., M.P.H.

Edition details

• Publisher: Oxford University Press
• Publication date: 1998
• Language: English
• ISBN 10: 0195113977
• ISBN 13: 9780195113976
• Binding: Hardcover
• Edition number: 1
• Number of pages: 336