In this series, I dig a little deeper into the meaning of psychological terms.
This week’s term: Autonomy
While autonomy falls more under the umbrella of philosophy than psychology, it’s also has significant implications when it comes to mental health and mental health care.
The philosopher Immanuel Kant identified several key elements of autonomy, including both the right and the capacity to make one’s own decisions independently after personal reflection, and without interference. He believed that autonomy is necessary for a meaningful life.
In the field of medicine, informed consent is based upon the principle of autonomy. Autonomy runs counter to a paternalistic doctor-knows-best kind of approach. Complications can arise when a person’s capacity for autonomous decision-making is limited in some way. Other ethical principles may come into conflict with autonomy, such as beneficence (do good) or non-maleficence (do no harm). An article in the Canadian Journal of Psychiatry describes a concept called “supported autonomy”, which comes from the belief that “to support autonomy in the long term, it may be necessary to compromise autonomy in the short term”.
The Oxford Handbook of Psychiatric Ethics states that:
“The lack of a neat, necessary connection between irrationality and mental disorder calls into question the assumed, straightforward, link between psychiatric diagnosis and decision-making abilities.”
It adds that some jurisdictions take the view that mental illness impairs insight, autonomous control, and rationality, and as a result the presence of a diagnosis “eliminates the need to assess the person’s decision-making ability”. Other areas use a mental capacity approach that requires a separate functional assessment rather than the diagnosis alone to evaluate the individual’s capacity to make decisions.
Autonomy is popular for government and health care organizations to talk about, but how well does this translate into reality? The Australian Department of Health has a non-binding National Framework for Recovery-Oriented Mental Health Services, and it describes “promoting autonomy and self-determination” as an element of recovery-oriented services. It lays out what this might look like in practice, but as a non-binding document it’s really just a suggestion.
Ireland’s Health Information and Quality Authority has a guidance document for supporting people’s autonomy; again, this is non-binding. It rather euphemistically states that there are a “number of factors potentially affect the extent to which a person’s individual choices can be facilitated”.
I’ve had three involuntary hospitalizations, and I really struggled with the loss of autonomy. The power imbalance was huge, and while I didn’t necessarily have a problem with the medications or the ECT treatments that were ordered, having the choice of whether or not to be in hospital taken away from me was devastating. I’ve always been a very independent person, and it drove me crazy (crazier?) to be told that these doctors, whose competence I had serious concerns about, were in a better position than I was to make decisions about what happened to me. The powerlessness brought out very primitive behavioural responses, and I went so far as screaming at my doctors when they tried to exercise their power and suppress my own.
From my experience working as a mental health nurse I know there are times when hospitalization is absolutely necessary to protect someone. However, I believe that when an individual is being treated involuntarily the treatment team should be bending over backwards to allow the patient to exercise as much autonomy as possible within the confines of what needs to be done to keep them safe. In reality, that is seldom if ever the case. I think that somehow we need to find a way to convey to those who are not afflicted with mental illness how soul-destroying it can be to have one’s autonomy stripped away.
Autonomy is not just lost because of others, though. The illness itself erodes the ability to freely make choices and then enact those choices. While this effect is perhaps more pervasive in my life, it’s still easier to wrap my head around than externally imposed limitations on autonomy.
Have you experienced a loss of autonomy related to your mental health condition? How have you dealt with it?
Craigie, J., & Bortolotti, L. (2014). Rationality, diagnosis, and patient autonomy in psychiatry. In The Oxford Handbook of Psychiatric Ethics, volume 1.
Neilson, G., & Chaimowitz, G. (2015). Informed consent to treatment in psychiatry. Canadian Journal of Psychiatry, 60(4), 1-11.