Takeaway
Respecting patient autonomy means honoring their decisions even when they go against clinicians' medical judgment.
Lifelong Learning in Clinical Excellence | February 25, 2025 | 3 min read
By Drs. Shriganesh Naidu, Madras Medical College, Chennai, India & Carolina Musri, Johns Hopkins Medicine
In medicine, the balance between respecting patient autonomy and ensuring their safety is often a delicate and challenging one. A recent encounter during my time as an observer at Johns Hopkins brought this ethical tension to light in a profound way, leaving me with lessons that will shape my approach to patient care for years to come.
A patient presented with urinary retention and required the placement of a suprapubic catheter. While the medical management was straightforward, his discharge planning revealed a cascade of social and environmental challenges.
The patient’s home environment was starkly inadequate. During one of the coldest weeks in Baltimore, his house lacked proper heating and even basic accommodations like a good bed. Compounding this, he had strained relationships with family members, leaving him isolated and without a support system. Despite these hardships, he was resolute in his decision to return home.
This scenario was surprising to me because of how it contrasted with my experiences in India. There, the discharge planning often doesn’t take into consideration a patient’s home situation. The focus is on ensuring that patients leave the hospital with their only medical issues addressed. Challenges like inadequate housing or lack of family support are often considered outside the purview of medical care and are left to the patient to manage.
Medically, the team deemed it conflicting to discharge him to such conditions, where his health and safety would be at significant risk. On one hand, the team wanted to prioritize his safety and well-being by recommending placement in a care facility, thereby upholding the ethical principle of beneficence by aiming to provide the best possible care. On the other hand, we were bound by the principle of patient autonomy, the right of an individual to make decisions about their own care, even if those decisions seem counter to their best interests.
Multidisciplinary discussions ensued, involving physicians, nurses, social workers, psychiatry, and geriatric medicine. Each team member brought unique perspectives, offering possible solutions while respecting the patient’s autonomy. After thorough evaluation, it was confirmed that the patient had full mental capacity. He understood the potential consequences of his decision, including the challenges and dangers of living alone in such an environment.
Despite repeated efforts to present alternatives, including temporary stays in a care facility or outreach to distant family members, the patient remained steadfast in his desire to return home.
Ultimately, the team made the decision to respect his autonomy. A wheelchair was arranged to accommodate his mobility needs, and the discharge was planned with additional provisions to maximize his safety. With these measures in place, the patient was discharged to his home.
As he left the hospital, I couldn’t help but feel conflicted. Had we done enough? Was honoring his autonomy the right choice in this situation? These questions lingered long after his discharge, reflecting the inherent complexity of ethical decision-making in medicine.
Reflections and lessons learned
This encounter left a lasting impression because it highlighted the core ethical challenge of balancing autonomy with beneficence. Here are the key takeaways from this encounter:
1. Patient autonomy is a cornerstone of care, even when it challenges our instincts as caregivers.
2. Understanding the patient’s social context is essential to providing truly patient-centered care.
3. Respecting autonomy while mitigating harm requires creativity and teamwork. Collaborative efforts can help find solutions that align with both ethical principles and practical realities.
4. Patient-centered care extends beyond the hospital walls.
The art of medicine lies in navigating the grey areas. While there may not always be a clear answer, what matters most is the commitment to treat patients as partners in their care, respecting their autonomy and supporting their decisions, even in the face of uncertainty.
This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.