An ethical case for patient self-determination.

The self-determination of patients can be impeded or enhanced to a significant extent by the professionals who care for them. The autonomy of cancer patients especially is affected by their care givers. These patients often face difficult choices in the management of their illness: decisions about pain control, treatment choice, research participation, family involvement, withdrawal of treatment, and the degree to which they wish to be informed in making each of these decisions. The extent to which consent is free and informed and the autonomy of the patient not impeded, but positively enhanced, is determined by the professional. Is it fair to assign the professional so much responsibility for patient autonomy? Are patients not free to make decisions as they wish? In a technological society, serious illness is managed by professionals who incur a major share of responsibility for the degree of freedom that patients exercise. When patients are not encouraged and assisted to exercise their freedom, they cannot be autonomous. When an experience is brought under professional management, self-determination is possible only to the extent that it is both protected and promoted, or actively advocated. In the care of cancer patients, the central responsibility for advocacy belongs to the professional best situated within the framework of health care to sustain a partnership with the patient, and that professional is the nurse.