The Academy Of Medical Royal Colleges: A Discussion

Respecting Patient Autonomy

Discuss about the Academy of Medical Royal Colleges.

Autonomy is the ability or right of an individual to exercise the necessary freedom of self-government[1]. When an individual is capable of deciding the personal objectives, without any influence, the individual is said to be autonomous. The respect of autonomy is crucial in medical practices to be called reasonable. Respecting the autonomy of an individual refers to giving necessary weightage to their choices, as well as, their opinions, without any kind of interference, unless and until, such results in harm to the others. The freedom to act gets infringed, if this autonomy is denied.

As the life of a person progresses, the autonomy also transforms, where at this, this autonomy is completely lost, partially or completely, as a result of immaturity, imprisonment or illness. Just because a person is incapacitated, their autonomy cannot be disrespected or less protected. The respect for patient’s autonomy presents a range of difficulties in delivering the healthcare, especially in the cases where the patient is imprisoned, incompetent or comatose. A retarded person’s autonomy is limited by incapacitation and that of a prisoner is limited by coercive institutionalization. In such situation where the person does not have autonomy, they can be easily influenced by other people. The lack of autonomy becomes a hurdle in the clinical setting when informed consent, voluntariness, comprehension and disclosure are required[2]. For the decision of a patient to be taken autonomously, it has to be made by a competent person in an informed and voluntary manner.

In the case of C. v. Wren[3], C was a 16 year old girl, who was pregnant, and left the home to arrange for an abortion. Since her parents were against the abortion, they wanted to stop the procedure and claimed that C did not have the capacity to consent. While deciding if the patient has to be given the autonomy to make their choice, the doctor has to consider the capacity and competency of the patient, in making rational decisions. The autonomy has to be free from any controlling influence, and the decision has to be taken by the medical practitioner on the basis of rationality of the patient[4]. When a patient can think, decide and act freely, as well as, independently, such patient is autonomous[5]. In the given case, the patient’s decision would not harm anyone and she knew the result of her choices. And this is the reason why court ruled in C’s favor, and the wishes of her parent were not taken to be relevant. So, it can be concluded that respect for autonomy is present in clinical situations.

Maintaining Patient Confidentiality

The general well being and the welfare of the people, is referred as public interest. And it is known fact that the patient confidentiality has to be upheld. As highlighted in the previous question, the respect for autonomy gives the right to the patient to exercise control over their life. To certain extent, the decision regarding the access to the information of patient is also included in this. If there is a breach in confidentiality, the doctor loses their patient[6].

Article 8 of the Human Rights Act, 1998[7] provides the right of a person to protect their personal and family life. As per this act, the public authority should not interfere with this right, unless in case of national security, economic wellbeing of country, prevention of crime or disorder and public safety. The personal data of the individuals is protected trough the Data Protection Act, 1998. The Health Records Act, 1990 provides the right to access the health information to the patients[8].

In the case of W v Edgell[9], W was convicted for murdering 5 people, along with injuring others. A request was made to the mental health tribunal by the patient to transfer him to a regional unit. Dr. Edgell was requested by the legal counsel of the patient to state in his expert opinion that W was not a threat to the world. As the doctor had a contrary view, the application of W was withdrawn. Dr. Edgell also sent the copies of patient’s note to the home office and the medical director of the hospital. He was sued by W for a breach of confidence.

The judge held that the duty of confidence of a doctor, towards his patient, along with the need to preserve the general reliance on this confidence, can be possible overridden in such cases, where there was an actual risk of violence to the others. To maintain the duty of confidence was a public interest matter and not a private one and so, the public interest had to be balanced, in terms of protecting the members of public from acts of violence. The court held that the actions of Edgell were justified and the breach was in public interest, hence, justified.

The healthcare professionals are under the obligation to provide the best possible treatment to their patients, which is available to them, and which is within the limits of law. As per Article 2 of the Human Rights Act, 1998[10], an individual cannot be intentionally deprived of their life, unless there is a case of the execution of a sentence of the curt for a convicted crime. As per Article 3[11], an individual cannot be subjected to degraded or inhumane treatment, and torture. As per Article 8[12], the individuals have the right to respect their family and private life. Unless a case of public interest is involved, the right has to be upheld[13]. As per Article 14[14], there is a restriction on any kind of discrimination. And so, the medical practitioners are expected to respect the right to life, autonomy of patient and not discriminate.

Examples from Notable Cases

In the matter of R (on the Application of Burke) v General Medical Council[15], R Burke had appealed against the ruling of court claiming that there was a breach with regarding to the guidance on withholding and withdrawing life prolonging treatment of GMC. R was suffering from the congenital degenerative brain condition, due to which the patient was confined to wheelchair. Even though his brain functioned in the correct manner, but the medical personnel were apprehensive about the other aspects of his life, as they were prone to deterioration. In such situation, the patient would have needed ANH, or the artificial nutrition and hydration through a tube for his survival. Based on the GMC guidance, the initial court had given its verdict that it was unlawful for the doctors to take away the ANH from any patient[16].

Though, this decision was overturned by the Court of Appeals (CoA) and provided that it the court was not to be used as the centre for general advice. Munby J, the previous judge, was accused of dealing with the public interest issues, instead of focusing over the specific case. The declaration of the GMC guidance was set aside by the CoA. The CoA also addressed the fears of the patient regarding the removal of ANH, whilst R was still competent in expressing his will. Regarding the GMC guidance, there was no need for making a declaration, as per the beliefs of the CoA[17]. And they viewed that as long as the treatment could prolong the life of R, and till his wishes are so, the doctors were under the legal obligation to provide ANH to R.

The process of finding the solution to the concerns regarding the performance with the objective of facilitating the practitioners to go back to safe practices is the remediation process[18]. If the patient views that they have received poor medical treatment, they may undergo the complaint process[19]. The complaints of the patients are initially dealt by the health and social care organizations at the local levels. The patients reach ombudsman only if the patients remain disgruntled or a point of understanding could not be attained. Through the complaint process, a medium is provided for both the patients and the practitioners to put the things in the right way.

Under the remediation process also, the issue is resolved at the local level[20]. In case, the grievance of the patient is not addressed properly, the patients have the right to approach the health service Ombudsman. Once a complaint is filed, the first stage of local resolution is initiated, under which a resolution is sought. This stage provides the unsatisfied patient with an opportunity to elucidate upon their grievances, and the likely result they want to achieve. The incident is discussed between the hospital and the patient at this very stage. Upon the complaint of patient being resolved, it is often used as a guidance to improve upon the hospital’s services.

The Remediation Process

The process is initiated when the patient makes a written complaint; in case a verbal complaint is made, instead of a written one, than the manager of the hospital writes down the complaint and provides the patient with the copy of same. As soon as the complaint is filed, the hospital responds to it, by informing the department or the person against whom the complaint has been made by the patient, so that the respective department or the person is aware about such complaint. The patient is then contacted by the department or the person, so as to try and resolve the issues of complaint. The complainant is informed at this stage regarding how the complaint would be dealt with.

Through an investigation or meetings where the patient is provided a chance to talk about the occurred incident, or by arranging a mediator, who could initiate meetings between the two parties, the problems are solved. Upon the completion of the investigation, the patient is contacted and informed the results of the investigations, as well as, the requisite steps taken. Even after the investigation, if the patient remains disgruntled, than the patient is free to file a complaint with the Ombudsman[21].

Bernard Gert, Charles M. Culver and K. Danner Clouser, Bioethics: A Return to Fundamentals (2^nd edn, Oxford University Press 2006)

Peter A. Singer and ‎A. M. Viens, The Cambridge Textbook of Bioethics (Cambridge University Press 2008)

A. Hope, Julian Savulescu and Judith Hendrick, Medical Ethics and Law: The Core Curriculum (2^nd edn, Elsevier Health Sciences 2008)

Angus Dawson and E Garrard, ‘In defence of moral imperialism: four equal and universal prima facie principles’ (2006) 32 J Med Ethics 200

David Gurnham, ‘Losing The Wood For The Trees: Burke And The Court Of Appeal’ (2006) 14 Medical Law Review

Academy of Medical Royal Colleges, ‘Remediation and Revalidation: report and recommendations from the Remediation Work Group of the Academy of Medical Royal Colleges’ (2016) <https://www.gmc-uk.org/Item_6e___Annex_E_AoMRC_Remediation_Report.pdf_28987523.pdf > accessed 03 January 2017

HSC, ‘Making a complaint’ (2016) <https://www.belfasttrust.hscni.net/contact/ComplaintProcedure.htm > accessed 03 January 2017

Jane Dryden, ‘Autonomy’ (Internet Encyclopedia of Philosophy, 2016) <https://www.iep.utm.edu/autonomy/ > accessed 03 January 2017

NHS, ‘The Back on Track Framework for further training’ (2016) <https://www.ncas.nhs.uk/resources/back-on-track-framework/> accessed 03 January 2017

Nir Eyal, ‘Informed Consent’ (Stanford Encyclopedia of Philosophy, 20 September 2011) <https://plato.stanford.edu/entries/informed-consent/> accessed 03 January 2017

Parliamentary and Health Service Ombudsman, ‘The NHS hospital complaints system A case for urgent treatment?’ (April 2013) <https://www.ombudsman.org.uk/__data/assets/pdf_file/0018/20682/The-NHS-hospital-complaints-system.-A-case-for-urgent-treatment-report_FINAL.pdf> accessed 03 January 2017

The BMJ, ‘GMC guidance on end of life care’ (2010) <https://www.bmj.com/content/340/bmj.c3231?tab=response-form> accessed 03 January 2017

The Guardian, ‘Human Rights Act 1998’ (19 January 2009) <https://www.theguardian.com/commentisfree/libertycentral/2009/jan/14/human-rights-act> accessed 03 January 2017tProcedure.htm > accessed 03 January 2017