Sunday, September 17, 2023

The Ethics of Autonomy (Self-Determination)


One of the ethical issues that came up frequently in our behavioral health unit was the issue of autonomy (Greek: self-law). If somebody wanted to die, did they have the right to die? Specifically, several older people on our unit underwent dialysis three times a week. They got tired of it, quit going, and decided they wanted to die. People interpreted this as a suicidal gesture, forcing them to be admitted involuntarily to our behavioral health unit.

The question arose: Did these people have the mental capacity to make this decision? One woman had a history of psychosis. Was she mentally competent to decide to quit dialysis? After her evaluation, the psychiatrist determined that the woman was not mentally competent to make this decision. The woman was held in our unit under Title 36 (involuntary commitment with all legal rights temporarily suspended) and forced to go to dialysis. Her daughter became her legal guardian, so the woman lost all legal rights to quit going to dialysis. The woman was unhappy with her life. Other people forced her to undergo a medical treatment she did not want.

Most of the nurses on the unit believed the woman had the right to quit dialysis if she no longer wanted it. Using the reasoning appropriate to Kohlberg’s Stages 5 and 6 of moral development, the psychiatrist was following the ethical code of her profession – do no harm – and protecting her professional license. The people who sent the patient to our unit were concerned about her well-being and did what they felt was right. The nurses advocated for the patient’s civil rights – autonomy and self-determination. Even if the patient had a history of psychosis, she had a right to stop treatment that was making her life unhappy. On the medical floor, if a patient deemed mentally competent decides to quit dialysis and die, nobody questions it. Their rights are not legally taken away because they chose to die. They designate themselves a “Do Not Resuscitate,” put their affairs in order, and let Mother Nature take its course. It’s a moral dilemma, dependent on the law, mental health vs. medical rights, and personal moral judgment.

If you were in this situation, what would you choose? What are your thoughts?

Dawn Pisturino

September 18, 2023

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