Can Autonomy Go Too Far?

Okay, so we live in a pretty autonomous society, right? Each person is an individual and gets to make his or her own choices. Do I want to buy a house or a town home? Do I want a Lexus or a Chevy? Do I want chocolate cake or vanilla? (Chocolate, hello!) At the same time, no one is an island and the “independent” choices one makes invariably spreads out to affect others. And in some cases, many others.

This very topic came up recently for me and I thought I’d share because it can be (and was) incredibly thought provoking.

For a little background, there are four “buzz-words” that get bandied about in psychiatry: Autonomy, Non-malfeasance, Benevolence, and Justice. I won’t get into the others here, but you can see which term is number one on the list. Basically, my goal is to collaborate with patients, connect with them, and guide them to their own decisions. Even if I disagree with their ultimate choice!

But when does the idea of letting someone make their own decisions go too far?

Here’s a real life case example to consider. In England, a young woman in her late twenties presented to the Emergency Room after drinking large amounts of a lethal substance. She explained what she’d done to the doctor and she asked that no life saving measures be taken. To her, she had an incurable personality disorder, and as such, life was no longer worth living. And she procured the legal documentation showing that she was of sound mind when she determined suicide was her best option. Acting under the rule of autonomy, she made the decision to  end her life. But she also affected several others in that process because she wanted to have company and comfort care while she died in order to ease her passing. So, after what I can only assume was a large amount of debating, perhaps with the legal and ethics teams present as mediators, the hospital complied with the woman’s wishes. They made her “comfortable” and they “let” her die.

As a physician, I’m in the business of keeping people alive, yet I also must give them the opportunity to make their own decisions regarding their health and body. Personally, I don’t know what I’d do if someone came under my care, told me that they did not want life-saving treatment for their suicidal act, and they “proved” to me that they had decision making capacity. Now, I don’t think a personality disorder is a “terminal” illness by any means, but then again I’m not living in that unfortunate patient’s shoes.

Bottom line: Could I “let” someone die right before my eyes knowing that if I saved them, they’d be alive, but their life would potentially be much worse (caustic chemicals do A LOT of damage)? Could I withhold treatment from them, thereby removing any opportunity for them to revoke their death wish? Could I trust that their decision was truly theirs and theirs alone?

Tell me, when we act of our own free will, who else gets to have a say in our decisions?

10 comments on “Can Autonomy Go Too Far?

  1. philangelus says:

    Anyone whom our actions would harm. I would say that the ER staff who were forced to watch her die were harmed by her actions. I would wonder if that weren’t a suicidal gesture on her part simply because there are more rapid and pain-free methods of suicide than ingesting a lethal substance. She had time to get to the ER, and they had time to convene an ethics panel. Did she want someone to prove she was worth saving?

    The individuals who had to make that decision are going to question themselves, remember her death, and possibly be sued by her estate because of her actions.

    At that point, I’d say her autonomy was no longer in force because she was involving others and therefore had surrendered part of her autonomy by that very act.

  2. ElanaJ says:

    This is such a hard question. Yeah, we get to act for ourselves, but every one of our actions most likely impacts someone else. For good or bad. That’s why other people influence our decisions so much, I think.

    Great post!

  3. lbdiamond says:

    Certainly, our actions do impact others. And I’m sure “our” concept of autonomy is very different from “another’s.” Interestingly, I was speaking with a physician trained in India and she said that her culture dictates including the entire family in health related decisions. For instance, if grandma has cancer, it is up to the family to decide if she’s even told and if she “accepts” treatment!

    In this case, it is difficult to speculate between suicidal “gesture” vs. “attempt.” Personally, I feel that since she showed up in the ER in the first place she was, in effect, asking for “help.” At the same time, she had thought out her options (for her), planned ahead (by getting legal documentation), and gotten her wishes respected.

    I still would not want to be the ER doc in that case. For sure.

  4. Bella says:

    Hmm, perhaps my answer is initially insensitive to the concept of autonomy, but ultimately it is not. I believe the proper resolution of the scenario you gave is to make every attempt to prevent harm. That means saving the girl. This is the best choice from a public policy standpoint. Chances are, with care and therapy, she may reconsider her decision.

    My answer to the argument that stopping her death is an interference with her autonomy is: yes it is, temporarily.

    If the woman remains intent on killing herself, she can prepare well enough to spare the rest of the world any sense of responsibility or conspiracy in her death.

    In sum, she is free to take her life wholly autonomously, that means without involving others.

    Cheers to your blog! *karma too*

  5. philangelus says:

    Laura, I was wondering on further thought, what kind of personality disorder did this woman have? Because it sounds incredibly narcissistic for her to have done what she did, knowing the emotional anguish it would cause, but caring only about her own comfort. Also a big “screw you” to the medical establishment by giving them a no-win scenario.

  6. lbdiamond says:

    Great question, philangelus. I do not know what type of personality disorder she had. And it is hard to interpret information when it has been filtered down into what amounted to a newspaper article, but I would guess this woman spent a great deal of her time suffering. And she’d concluded–based on the “evidence” of her personal experience–that life was nothing but pain. For some, when hope is lost, suicide becomes comforting. It gives the person a sense of control. However, the decision, if carried out successfully, is final…and incredibly tragic. In this case doubly so because she has left a legacy behind her.

    Additionally, there is a sense of “suicide is a selfish act” at times; it is also a rageful one. Again, in her case, I don’t know which (if either one) applied.

  7. philangelus says:

    Suicide can be selfish. It can also be an act of desperation. But the way she set it up, forcing the medical staff to stand by helplessly while she lingered long enough for them to actually convene an ethics panel — that kind of planning doesn’t seem like an act of desperation. It bespeaks a certain anger.

    We endured a suicide in our family, so I wouldn’t casually place blame. A person has to be in tremendous pain to consider ending it all. But this person’s method seems outrageous to me because in my experience, people who are depressed to that extent are the least likely to ask for help and the most likely to hole up and think no one cares about what they want anyhow (and hence, would not ask for this kind of medical standby.)

  8. LBDiamond says:

    I recently attended a grand rounds presentation on suicide and the presenter discussed specifically the trauma that survivors (family members, friends, treating clinicians) go through when someone they know commits suicide. It is an especially tough situation and I appreciate your sharing, philangelus.

    For sure, suicide can represent a lot of anger and I tend to agree with your comments. In this case, I don’t know how long it took for her to die, but she certainly left behind a legacy that is in some way spreading across the globe. To me, her action of showing up to the ER represents a “cry for help,” even when her words said “don’t.” The whole thing is confusing to say the very least.

  9. lilain says:

    This is a debate that, IMO, will never resolve. With so many differences in opinion, it seems impossible to come to a happy ground. Then again, that’s my cynical side talking. I have seen it from both POVs. One side is hurt by the loss of their loved one to suicide. The other side just needs relief from whatever is troubling them. Since I tend to honor people’s autonomy, I tend to lean in the direction of let the person have what they want… yet if they’re mentally ill, I pause in that thought.

    BTW, Laura, it’s lovely to visit your blog! I’m eager to read more and cheer you through your journey toward publication.

  10. lbdiamond says:

    Thanks, lilain! And best wishes to you as well!

    I agree–the debate will never resolve. Each person has their own perspective and sometimes there’s so many sides to a story that it’s hard to figure out what “really” happened.

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