Patient autonomy and choice in healthcare: self-testing devices as a case in point

Abstract

IntroductionThe growing number of self-testing diagnostic devices available for home use raises a number of ethical, psychological and social questions. Such devices allow individuals to test for a range of medical conditions in the absence of medical supervision. These devices are on sale in pharmacies, super-markets and a growing online industry where over a thousand tests are listed (Parliamentary Office of Science and Technology, 2003). It is now possible to test for HIV (albeit only one system approved) (Federal Drug Administration, (FDA) US, 2009), genetic markers (Levitt, 2001), response to coagulation therapy (Heneghan et al., 2006) and glaucoma (Ianchulev et al., 2005) without leaving one's home. The premise underpinning the nature and availability of these devices, which is noted in their marketing strategies, is that they assist individuals to be more autonomous in the assessment and management of their health by assuming a more independent role. Increased patient autonomy is assumed to be a good thing. In this paper we critique this assumption. We do not oppose patient involvement in care, but rather seek to critique a particular understanding of patient autonomy and its practical implications.We propose that diagnostic self-testing is a specific instance of the application of a developing model of patient autonomy in healthcare policy and practice. Recent legislative change and health policy in are claimed to support these views. We suggest that policy-makers have adopted these 'assumptions' to underpin current healthcare policy with little substantive debate.The aim of this paper is to reflect on these 'assumptions' and the extent to which autonomy, in so far as it is often construed as patient choice and freedom in decision-making, represents a progressive principle for healthcare delivery. The central thesis here is that current perceptions of autonomy do not represent a progressive philosophy for healthcare, as they fail to capture the multi-dimensional nature of the concept and undermine other significant issues such as relationality, care and responsibility.The paper draws on the philosophical literature and examples from the self-testing process to support this claim. The self-testing process represents a specific microcosm of greater patient involvement and autonomy in healthcare and therefore provides an ideal practical context for discussion. We conclude by offering an alternative account of autonomy which may better serve patients. We accept that autonomy is constituted, perceived and valued differently in various cultures. This paper draws primarily on the Irish, UK and US perspectives; therefore, we acknowledge that the discussion has relevance primarily in a Western context. 1 The argumentThe argument we propose may be outlined as follows. Current healthcare ethics and recent social policy documents uphold patient autonomy as a paramount ethical principle. This model of autonomy goes beyond merely encouraging participation as autonomy is increasingly portrayed as individual freedom to ...

Unsupervised Self-testing as Part Public Health Screening for HIV in Resource-Poor Environments: Some Ethical Considerations

“…Selftesting also fits well within current policy and rhetoric regarding individual responsibility for one's health and the onus on individuals to participate in their health care and in health service delivery [14,15].…”

“…However there is a growing critique of this conception of autonomy and its application within health care [7,14,42,43]. A richer understanding of autonomy recognizes that human beings do not exist or flourish in isolation.…”

“…In terms of the use of well-established self-testing devices such as pregnancy, cholesterol and prostatic antigen (PSA) tests for example, the demand and indeed the justification for the development and use of such tests is intimately linked with the notion of personal autonomy and the individual's right to information regarding health decisions as well as his or her right to participate in decisions affecting his or her health and life-style [13,14]. Selftesting also fits well within current policy and rhetoric regarding individual responsibility for one's health and the onus on individuals to participate in their health care and in health service delivery [14,15].…”

Ideal and nonideal moral theory for disaster bioethics

“…Within an ideal approach to ethics, one principle is necessary to provide a way to find clear-cut answers. However, the resulting priority given autonomy has been critiqued both on philosophical grounds (Greaney, O'Mathúna, & Scott, 2012) and on empirical grounds (Christen, Ineichen, & Tanner, 2014). While an ideal approach that claims to find clear solutions is attractive, in practice it generates further dilemmas, especially when conflicts arise between one person's autonomy and another's, and whether there are limits to one's autonomy.…”

Regions, concepts and integrations

“…Thus, he shows how it can be revised and refined to make it better applicable. Analyzing the concept of autonomy is a daunting task but it has not prevented Greaney et al (2012) to undertake it in connection to the growing availability of self-testing diagnostic devices. The authors not only deconstruct the notion as commonly used in bioethical discourse but they also provide a constructive account how the notion of autonomy should be used in a context of professional responsibility, care and solidarity.…”