What is autonomy in health care?

Autonomy is the idea that a person is free to make their own independent decisions. In health care, autonomy means a patient has the right to choose or to refuse any treatment offered or recommended, so long as the patient is mentally and physically capable of making such a decision. Even if the choices patients make seem like poor decisions, health care professionals are ethically bound to permit patients to determine what is in their own best interest.

Compared with other guiding principles, autonomy is a fairly recent addition to the field of medical ethics. Up until around the 1950s, almost all health care systems were based on paternalism. A paternalistic system assumes that the health care professional, not the patient, is the person who is best suited to determine which treatments a patient should agree to. In a limited number of cases, paternalism can be justified, such as when a patient is suicidal and a health care professional ignores a patient's decision to self-harm in order to save the patient's life. For the most part though, modern-day medical ethics rejects paternalism and attempts to create a health care experience based on patient autonomy.

Although autonomy is the goal, it’s not always possible. While most patients are physically and mentally capable of determining the course of their own treatment, others are not. Sometimes, a determination to forgo a patient’s autonomy must be made based on a patient’s capacity and competency.

A patient's capacity to make a reasonable decision is a clinical determination that is made by a qualified health care professional. In cases in which it is unclear whether a patient has that capacity––for example, in cases of dementia––a patient can be evaluated and assessed. If enough medical evidence of a diminished capacity exists, those people close to the patient can begin legal proceedings to have that patient declared incompetent.

Whereas capacity is a clinical term, competency is a legal one and must be decided in a court of law. If a judge rules that a patient is not competent, autonomy is revoked and the power to make decisions on behalf of that patient is given to someone else, such as a spouse, child, or close family member. However, if a patient retains the clinical capacity and legal competency to make decisions on her own behalf, then, according to modern medical ethics, that patient is granted the autonomy to make whatever treatment decisions she feels are best for her.