Patient autonomy in real life


Wednesday, November 6th, 2013

From very early on in our medical training, we are taught the importance of patient autonomy. We all know that this is one of the basic principles of medical ethics and that we must always respect it. In preparation for entering the clinical years, we are taught of how to respond when put in a situation that might cause us as students to compromise a patient’s autonomy. Unfortunately, these discussions often fail to recognise the social aspects of situations that students end up in and do not provide adequate advice on how to realistically respond.

During the preclinical years, most of us have probably been presented with a hypothetical case where we are asked to examine an unconscious patient strictly for our own practice who has not consented to being examined by a student. After much discussion, some “solution” will be presented that is meant to allow the student to maintain the patient’s autonomy without jeopardizing the medical student’s relationship with their supervisor. One favourite answer at my medical school to this hypothetical scenario is to play the role of the naive medical student. They suggest that we ask the doctor who suggested we examine the patient how that informed consent thing we learned about in medical school comes into play in a situation like this. In the hypothetical discussions, this prompts the staff member to reconsider their suggestion, apologise for putting you in that situation, and commend you for your patient advocacy. Real life isn’t this easy.

I recently found myself as one of a small group of junior medical students in an intensive care unit. When we checked in with the consultant as instructed, we were immediately each assigned a patient to examine and then present to the consultant. These patients were all unconscious, intubated, and none had provided specific consent for medical students to be touching their unconscious bodies. Despite my attempts to tactfully play the naive medical student as we had been taught, we were told simply that this is what all of the other medical students have done and we need to learn. This isn’t like what had happened in those hypothetical discussions in the preceding years.

The options are clear when in a situation like this. You can choose to violate the patient’s autonomy, no one would ever question you on it, and you will learn from examining the patient. Alternatively, you can stand up for the patient, potentially burning a bridge with the consultant, and making waves at the medical school.

I took the easier way out. I regret that that is what I did, but the reality is that the situation does not leave much room for choice for a student who is trying not to stand out. The social pressures for medical students to follow the instructions of their seniors are quite strong. The ethical discussion around cases like these during the preclinical years should shift from only talking about what is ethically right to actually addressing the critical social component of these situations.