Davies Myfanwy, Elwyn Glyn
Department of Primary Care and Public Health, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN, UK.
Health Care Anal. 2008 Dec;16(4):315-28. doi: 10.1007/s10728-007-0075-3. Epub 2007 Nov 2.
Promoting patient autonomy has become a key imperative in health service encounters. We will examine the potential negative effects of over-promoting patient autonomy and consider the impact on patient access, their experience and the provision of equitable services by focusing on an extreme manifestation of this trend, i.e. calls for patient involvement in health care decision making to be mandatory. Advocates of mandatory autonomy hold that patients have a duty to themselves, to society and to the medical system to make decisions on their health care independently. Models of mandatory autonomy may be contrasted to those of optional autonomy that seek to ascertain patients' decisional preferences and to understand wider limitations on their freedom to choose. Where choice as decisional responsibility becomes mandatory it ceases to promote agency and where autonomous choice is understood as an individualistic practice it will contribute to the cultural dominance of Western values. Moreover, taking a view that principlist ethics needs to take account of the social and cultural contexts of individual lives, we argue that if mandatory autonomy were to be over-emphasised as part of an ongoing move towards patient choice in UK National Health Service (NHS), educated and affluent people would be more able to exercise choices at the expense of people who are experienced in asserting preferences and who have the resources to make use of choices. We will argue that the promotion of autonomy needs to be tempered by steps to enable less powerful social, cultural and economic groups to contribute to decision making and to support individuals who may feel abandoned by having decisional responsibility transferred to them. Until constraints on individual choice can be understood and addressed, we advocate the model of optional autonomy used in shared decision making and make recommendations for practice, policy, education and research.
在医疗服务过程中，促进患者自主性已成为一项关键要务。我们将审视过度强调患者自主性可能产生的负面影响，并通过聚焦这一趋势的极端表现形式，即要求患者参与医疗决策成为强制性要求，来考量其对患者就医机会、就医体验以及公平服务提供的影响。强制性自主性的倡导者认为，患者有责任为自己、为社会以及为医疗系统独立做出医疗决策。强制性自主性模式可与选择性自主性模式形成对比，后者旨在确定患者的决策偏好，并了解其选择自由所受到的更广泛限制。当作为决策责任的选择变为强制性时，它就不再促进能动性；而当自主性选择被视为一种个人主义行为时，它将助长西方价值观在文化上的主导地位。此外，鉴于原则主义伦理学需要考虑个体生活的社会和文化背景，我们认为，如果在英国国民医疗服务体系（NHS）朝着患者选择的持续转变过程中过度强调强制性自主性，受过教育且富裕的人群将更有能力做出选择，而这是以那些善于表达偏好且有资源利用这些选择的人群为代价的。我们将论证，促进自主性需要通过采取措施来加以调和，以使社会、文化和经济上较弱势的群体能够参与决策，并支持那些可能因决策责任转移到他们身上而感到被抛弃的个体。在能够理解并解决对个体选择的限制之前，我们倡导在共同决策中采用选择性自主性模式，并针对实践、政策、教育和研究提出建议。
