Patient autonomy is the right a patient has to choose from the treatment plans suggested by the healthcare provider. It is also the right to accept or refuse treatment no matter how grave the consequences might be. The aim of this is to ensure that the integrity, rather than the welfare of the patient is upheld and to see that due respect is given to the patient’s autonomy and his dignity.
Lord Donaldson in stressing the importance of patient autonomy, evinced that an adult patient who suffers from no mental incapacity has the absolute right to choose whether to consent to medical treatment or not. He stressed further, that this right is exercisable notwithstanding whether the reasons for the decisions are rational or irrational, unknown or even non-existent.
It is therefore ethically and legally unacceptable for a healthcare provider to administer medical treatment or intervention, contrary to the patient’s decision or without the patient’s consent, after ascertaining that he is of a sound mind and understands the consequences of his decisions. Although certain exceptions may operate to vitiate this right from being exercised by the patient directly, the Healthcare Provider is enjoined, as a matter of ethical precaution to always explore the nature of the case before proceeding with the treatment.
In this article, we will be looking at the exercise of patient autonomy in psychiatric treatment and the hindrances that operate to limit same.
Competence and Capacity of psychiatric patients:
Competence refers to the soundness of mind of the patient. The Black’s Law Dictionary defined it as having sufficient ability…possessing the requisite natural or legal qualifications to make decisions.
Capacity on the other hand refers to the assessment of the individual’s psychological abilities to form rational decisions, specifically the individual’s ability to understand, appreciate and manipulate information and form rational decisions.
It is crucial for a patient to be mentally sound in order to exercise the right of autonomy personally. That a patient can make certain decisions is not a conclusive proof that he can actually decide on matters concerning his health. The UK Supreme Court in the case of Montgomery v. Lanarkshire Health Board made a salient point worthy of note, in discussing this subject. It held inter alia:
“An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo…”
According to the decision of the Court in the case supra, only competent patients can exercise autonomy. Competence in this circumstance is measured by the patient’s ability to understand the treatment plans suggested by the Healthcare Provider and make decisions thereto.
It is instructive to note that although signs of unsteadiness, silliness, and lack of intellectual coordination, may be likely signs of incapacity, the patient should not to be automatically considered incapable of exercising this right or be sufficient grounds to waive his right. For a patient to be adjudicated incompetent, there must be clear and convincing evidence based on the evidence presented by a licensed Health Care Practitioner.
PSYCHIATRIC PATIENTS IN THE EXERCISE OF THE RIGHT OF AUTONOMY
As a general rule, where an adult patient lacks the requisite capacity to make healthcare decisions, because of his mental condition, no matter how articulately couched, grammatically composed, and persuasively rendered his decisions may be, it should not be considered. Serious mental conditions like; severe bipolar disorder, severe major depression, and schizophrenia are examples of mental conditions that can limit a patient from exercising this right.
Doyal and Sheather lucidly explained that a schizophrenic patient with delusions about being poisoned, and being a danger to himself or to others, may not be able to understand or believe any information that contradicts this belief and thus not fit to exercise autonomy in his treatment.
In this circumstance, the Healthcare Provider may obtain a valid authorization to administer treatment or an appointed representative may decide on behalf of the patient. This requirement differs from jurisdiction to jurisdiction.
Psychiatric Patients Deemed Competent:
Patients undergoing psychiatric treatment who are diagnosed with mild mental illnesses and certified fit by a licensed Psychiatrist to make decisions may be competent to accept or refuse treatment for physical illnesses. Conditions such as mood disorder, eating disorder, and post-traumatic stress disorder (PTSD), may not be severe enough to completely extinguish the patient’s right of autonomy. For patients with such conditions to exercise their right of autonomy, a proper assessment should be done to ascertain their level of cognition.
When patients are compelled to undergo treatment they do not want under this circumstance, the psychiatrist may be held in breach of his (patient’s) right.
SOME HINDRANCES IN THE EXERCISE OF PATIENT’S AUTONOMY IN PSYCHIATRIC TREATMENT
Some of these problems are
- Poor mental health: Patients with severe mental illnesses such as psychotic disorders, severe major depression, and schizophrenia; may not be fit to exercise the right of autonomy in treatment. Bergamin and others explained that rigid dysfunction beliefs (I am worthless) common in mental disorders hamper the exercise of patient autonomy.
- Emergences: Where the life of the patient is threatened and there is no opportunity for the Healthcare Provider to obtain his consent, he can invoke the implied consent of the patient. However, where the patient has an advance treatment directive, the Healthcare Provider is advised to stick to the same.
- Some jurisdictions do not consider psychiatric patients capable of exercising the right of autonomy.
One would ordinarily think that given the requirement of mental sanity in exercising patient autonomy, psychiatric patients are completely foreclosed from having a taste of this gesture. This thought process, given certain considerations, is faulty. The Healthcare provider is therefore always advised to be vigilant of the case at hand, to know how to navigate through the ethical dilemmas that may arise, to avoid breaching the patient’s rights.
- Black HC. Black’s Law Dictionary, 5th ed. St. Minn; West Publishing Company 1979 257, p.257
- Chester v. Afshar (2004) UKHL 41
- Grannum v. Berard, 422 P 2d 812, 814
- Jessy Bergamin and others, ‘Defining Autonomy in Psychiatry’ Conceptual Analysis Article, Frontiers in Psychiatry Psychopathology, 31 May, 2022. Department of Psychiatry, Amsterdam UMC, Amsterdam, Netherlands/
- Len Doyal and Julian Sheather, “Mental Health Legislation should respect decision making capacity” BMJ. 2005 Dec 17: 33`1(75300 1467-1469.
- Montgomery v. Lanarkshire Health Board (2015) UKSC 11
- Raphael Leo, “Competence and the Capacity to make Treatment Decisions: A Primer for Primary Care Physicians” Primary Care Companion to The Journal of Clinical Psychiatry.
- Re T(Adult) (1992) 4All ER 649
 Raphael Leo, “Competence and the Capacity to make Treatment Decisions: A Primer for Primary Care Physicians” Primary Care Companion to The Journal of Clinical Psychiatry,
 Chester v. Afshar (2004) UKHL 41
 Ibid, Lord Steyn.
 Re T(Adult) (1992) 4All ER 649
 Black HC. Black’s Law Dictionary, 5th ed. St. Minn; West Publishing Company 1979 257, p.257
 (2015) UKSC 11
 Grannum v. Berard, 422 P 2d 812, 814
 Len Doyal and Julian Sheather, “Mental Health Legislation should respect decision making capacity” BMJ. 2005 Dec 17: 33`1(75300 1467-1469. accessed on www.ncbi.nlm.nih.gov
 Ibid, Len Doyal and Julian Sheather
 Jessy Bergamin and others, ‘Defining Autonomy in Psychiatry’ Conceptual Analysis Article, Frontiers in Psychiatry Psychopathology, 31 May, 2022. Department of Psychiatry, Amsterdam UMC, Amsterdam, Netherlands accessed on www.frontiersin.org/articles/10.3389/fpsyt.2022.801415/full