Caring, patient autonomy and the stigma of paternalism

Abstract

This paper utilizes data generated during a qualitative study in palliative and maternity care settings to guide discussion of the current discourse, which emphasizes patient autonomy and derides paternalism. Data are presented which illustrate that this ideology is established in nursing practice. Respect for patient autonomy is identified as an essential element of individualized, patient-centred and ethical care but conversely, it is suggested that overemphasis may confuse and suppress beneficent intervention. The value of ethical theory to provide an objective means to explore ethical dilemmas in practice is not debated, but exploration of the issues raised by the data suggest, that principle-based ethical theory suffers the following constraints: the predetermined balance of ethical principles in favour of respect for autonomy prevents an unbiased perspective and optimum guidance; in contrast to caring relationship, application of ethical theory does not reveal the particulars necessary to guide ethical decisions aimed at promoting good for the individual; current discourse appears to disregard the inherent inequality in the relationship between the helped and helper and practitioners' need to preserve their own moral integrity. Consequently, this paper argues that beneficence derived through caring should not be superseded uncritically and suggests that mutual nurse-patient relationship, which balances respect for patient autonomy and beneficent guidance based on practitioner's clinical expertise, protects the moral integrity of both patient and practitioner. For conciseness, the term patient will be used to indicate recipients of both nursing and midwifery care and while both nurses and midwives are not always specified, any term referring to nurses, denotes both.

Nutritional implications of patient–provider interactions in hospital settings: evidence from a within-subject assessment of mealtime exchanges and food intake in elderly patients

“…Results also revealed that patients' expression of more dominant (vs submissive) behaviours toward providers was positively related to both protein and energy intake measures. The beneficial impact of patients' agency echoes existing evidence for the adaptive role of one's autonomy on performance, well-being, medical compliance and learning (for a review see Ryan and Deci, 2000), as well as the current interest for more patient-centred and autonomy-supportive care (Woodward, 1998). Evidence also exists that one's autonomy can be fostered through social environments that are promoting choice, volition and freedom (Ryan and Deci, 2000).…”

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

“…Whilst the medical and collaborative models of self-care and self-management are perceived by professionals as a legitimate and expected patient behaviour (Coates and Boore, 1995), there appears to be contrasting anxiety from the patient's perspective as to whether professionals see their self-care as legitimate (Stevenson et al, 2003). It should also be acknowledged that some patients may prefer to be managed rather than to self-manage (Woodward, 1998), and within the current policy climate of self-management not only being regarded as a right but also an obligation (Gilbert, 2005) there is always the potential for promotion of selfmanagement being coercive.…”

“…Temptation to routinize care is very high when there are unrealistic work loads and time pressure (Woodward, 1998) whereas the nurse specialists were notable in working within clinics where there was sufficient time allowed to explore the patient perspective. Whilst the development of multidisciplinary teams is linked to the rhetoric of nursing autonomy, the reality is all too often that they are medically dominated (Cott, 1997).…”

Feminist Ethics Must Inform Practice: Interventions With Perinatal Substance Users

“…Critics suggest that an overemphasis on autonomy stands to dehumanize health care, overlook caring and relation, and suppress moral agency (Dunbar, 2003;Woodward, 1998). Balancing the autonomy of the pregnant woman with the best interests of the fetus will require development and support of systems of care that are holistic, contextual, and long term.…”