The justfiable limitations of patient autonomy in contemporary South African medical practice

[摘要] ABSTRACT: The European Enlightenment secured man's freedom from doctrinalthought. Scientific progress and technological innovation flourished inthe 18th Century, radically changing the lives of all. Man's mastery andtransformation of his environment was matched by revolutionarypolitical reform, resulting in the dissolution of empire and the transferof power into the hands of the people. Social transformation saw thecity-states of pre-modern man supplanted by a globalized communitywhose existence grew from time and space distantiation facilitated bythe new technologies and the development of symbolic forms. Thesesweeping social, political and ideological changes of the 18th Centuryfostered the belief that man's transformative authority was indeed histo command. Man believed he had a right to self-governance and toautonomous decision-making. Kant described moral autonomy as thefreedom men have to show rational accountability for their actions andhe saw in men a dignity beyond all price because of this moralautonomy. Personal autonomy is seen as the expression of the free willof individuals and is justifiably constrained by the need to respect theinterests and agency of others. The principle of autonomy, in thecontext of medical practice, was not clearly articulated until the early20th century. Prior to this, the ethical practice of medicine relied uponthe beneficent intentions of the practitioners. The limits to patientautonomy have been delineated largely by issues of social justicebased upon the need to share scarce resources fairly among membersof society. However, autonomy remains a dominant principle and ismost clearly exemplified by the process of informed consent obtainedprior to any medical intervention. This thesis provides a conceptualanalysis of autonomy in the context of informed consent. Followingthis, several different clinical scenarios are examined for evidence ofjustifiable limitations to patient autonomy. Each scenario is examined in the light of different moral theories including deontology,utilitarianism, communitarianism and principlist ethical reasoning.Kantian ethical reasoning is found to be resilient in rejecting anylimitation to the autonomy principle whereas each of the other theoriesallow greater scope for morally-justified curtailment of individualautonomy. The thesis concludes with reflection on post-modern societyin which the radicalization of what began with the EuropeanEnlightenment sees the transformation of pre-modern society into aglobal community in which epistemological certainty is no longeravailable. In this environment, the emerging emphasis on globalresponsibility requires ethical accountability, not only when individualssecure transactions between one another but also between individualsand unknown communities of men and women of current and futuregenerations. The thesis concludes that patient autonomy is justifiablylimited in South African medical practice because of issues related tosocial justice but that the impact of the new genetic technologies andpost-modernity itself may in future set new limits to individual patientautonomy.

[发布机构] Stellenbosch University