Autonomy and Neutrality

Autonomy and Neutrality

Freud (1912, 1913) recommended that psychoanalysts adhere to a position of neutrality with their patients by refraining from the temptation to take sides in the patient’s internal conflicts or life problems. This advice has relevance for all psychiatric treatment, insofar as it espouses the idea that practitioners should maintain profound respect for their patients’ autonomy and individuality. This is a fundamental therapeutic stance that fosters independ-ence, growth and self-esteem. It reinforces the idea that the clini-cian believes the patient to be the owner of his/her body, life and problems. The patient receives the following message:

The doctor tries to help by assisting me to learn about myself, not by trying to take control of me.

Patient autonomy has not always been accorded its current importance in the hierarchy of priorities in medical practice in the USA. According to Blackhall and colleagues (1995), in 1961, 90% of physicians in the USA did not inform their patients of a diagnosis of cancer. By 1979, 97% of American physicians made it their policy to inform patients with cancer of their diagnosis (Blackhall et al. 1995). This change appears to be the result of physicians assuming less of a paternalistic attitude and becoming more enlightened and respectful of patients’ right to participate in medical decisions. In some parts of the world, similar changes have occurred in clinical practice with mentally ill patients.

Cultural, ethnic and probably sociodemographic factors strongly shape attitudes regarding patient autonomy and in-formed consent. In some cultures, a higher value may be placed on the harmonious functioning in the interlocking pattern of family relationships than on the autonomy of individual family members. For example, according to Okasha (2000), patients reared in some cultures may not wish to continue treatment with a physician who is not sensitive to the importance of involving the family directly in communications about the patient’s illness. The psychiatrist should diligently explore the role that cultural and family relationships play in the patient’s healthy mental functioning and be guided primarily by the patient’s communica-tions about their degree of comfort or conflict with these family relationships. Psychiatrists should be considerate and respectfulof cultural differences between themselves and their patients and be particularly cautious about interpreting those differences as a pathological process.

Mindful of cultural issues, indicated ways of encouraging autonomy include encouraging informed consent by outlining the potential benefits, risks and alternatives for a proposed treatment approach; explaining the rationale for the treatment; and fostering the patient’s participation in the treatment process. Paradoxically, acutely suicidal patients often require the psychiatrist to assume temporary responsibility for their safety. In most cases this serves to augment the patient’s sense of autonomy through a coherent modeling process (Bratter, 1975), because true independence is impossible without self-governance.

Clinical actions that may interfere with the patient’s autonomy include advice regarding nonurgent, major life deci-sions, attempting to exert undue influence on issues unrelated to the patient’s health, reluctance to allow patients to terminate treatment, seeking gratification by exerting power over patients, and using power over patients as a form of retaliation.