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Mark R. Tonelli, MD, FCCP; Cheryl J. Misak, DPhil
Author and Funding Information

From the University of Washington (Dr Tonelli); and the University of Toronto (Dr Misak).

Correspondence to: Mark R. Tonelli, MD, FCCP, Box 356522, 1959 NE Pacific St, Seattle, WA 98195-6522; e-mail: tonelli@uw.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(2):476-477. doi:10.1378/chest.10-2485
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To the Editor:

Drs Black and Morrissey assert that our cautionary note regarding overreliance on the notion of individual autonomy in the care of the critically ill1 does not contain a rigorous account of the principle of autonomy, rendering our conclusions suspect and our recommendations unhelpful. Although we certainly agree that much more has and can be said regarding what autonomy is and what autonomy means, a full explication of autonomy was not our purpose nor necessary to our argument. Descriptions of the conceptual evolution and competing theories of autonomy in medical ethics can be found elsewhere.2 For our purposes, it is enough to note that autonomy, regardless of formulation, always means more than decisional capacity and requires both moral agency and freedom from undue influences. Patients who are critically ill, however, will virtually always have their autonomy compromised by both internal and external factors. The fact that we do not intend to interfere with our patients’ autonomy does not alter the fact that we invariably do as we strive to exert control over the physiologic perturbations that threaten their existence. If we are successful, we will ultimately restore to the patient the capacity of autonomous choice.

Our primary exhortations to clinicians, then, were to avoid confusing decisional capacity with autonomy and to not cleave too closely to the notion that exercising a patient’s autonomous choice is the only way to be certain that one is acting in a morally defensible manner. Agreement on a more rich and rigorous understanding of the notion of autonomy is not necessary. While we wish we could offer clinicians a simple tool for assessing the capacity of individuals to make truly autonomous decisions, for now at least, the assessment requires a clinician to make a conscientious attempt to understand the inner state of the patient, including the internal and external influences that impede autonomous choice, rather than simply assuming that statements of choice can be accepted at face value. Clinicians should feel comfortable making best-interest assessments regarding the care of their patients and should make those assessments explicit when necessary. The choices of nonautonomous individuals are not to be respected when one knows that harm will follow. To say that the principle of autonomy rests on the ability of the individual to make autonomous decisions is not a tautology; if a patient is unable to make autonomous decisions, the clinician who relies on the articulated choices of such a patient to determine the course of care will be making a clinical and a moral error.

Tonelli MR, Misak CJ. Compromised autonomy and the seriously ill patient. Chest. 2010;1374:926-931. [CrossRef] [PubMed]
 
Beauchamp T, Childress J. Principles of Biomedical Ethics. 2008;6th ed New York, NY Oxford University Press
 

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Tonelli MR, Misak CJ. Compromised autonomy and the seriously ill patient. Chest. 2010;1374:926-931. [CrossRef] [PubMed]
 
Beauchamp T, Childress J. Principles of Biomedical Ethics. 2008;6th ed New York, NY Oxford University Press
 
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