Nessa J, Malterud K
University of Bergen, Norway.
J Med Ethics. 1998 Dec;24(6):394-400. doi: 10.1136/jme.24.6.394.
Patient autonomy has gradually replaced physician paternalism as an ethical ideal. However, in a medical context, the principle of individual autonomy has different meanings. More knowledge is needed about what is and should be an appropriate understanding of the concept of patient autonomy in clinical practice.
To challenge the traditional concept of patient autonomy by applying a discourse analysis to the issue.
A qualitative case study approach with material from one consultation. The discourse is interpreted according to pragmatic and text-linguistic principles and provides the basis of a theoretical discussion of different concepts of patient autonomy.
The consultation transcript illustrates how the patient's wishes can be respected in real life. The patient, her husband and the doctor are all involved in the discourse dynamics, governed by the subject matter, namely her mental illness.
We suggest a dynamic and dialogue-based conception of autonomy as adequate for clinical purposes. These perspectives, based on mutual understanding, take communication between patient and doctor as their starting point. According to this approach, autonomy requires a genuine dialogue, an interpersonal mode of being which we choose to call "authentic interaction".
患者自主权已逐渐取代医师家长主义成为一种伦理理想。然而，在医疗背景下，个人自主原则具有不同含义。对于在临床实践中何为以及应如何恰当地理解患者自主权概念，仍需更多了解。
通过对该问题进行话语分析来挑战传统的患者自主权概念。
采用定性案例研究方法，以一次会诊的材料为依据。根据语用学和文本语言学原则对话语进行解读，并为关于不同患者自主权概念的理论探讨提供基础。
会诊记录展示了在现实生活中患者的意愿是如何得到尊重的。患者、其丈夫和医生都参与到受主题（即她的精神疾病）支配的话语动态之中。
我们建议将一种基于动态和对话的自主权概念视为适用于临床目的。这些基于相互理解的观点以患者与医生之间的沟通为出发点。按照这种方法，自主权需要真诚的对话，一种我们选择称之为“真实互动”的人际存在模式。
