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This chapter discusses the second topic that is essential to the analysis of an ethical problem in clinical medicine, namely, the preferences of patients. By preferences of patients we mean the choices that persons make when they are faced with decisions about health and medical treatment. These choices reflect the patient's own experience, beliefs, and values as informed by the physician's recommendations. The previous chapter, “Medical Indications,” concerns the physician's clinical judgment about a patient's medical condition and about interventions that might objectively improve deficits in that condition. When there are medical indications for treatment, a physician should propose a treatment plan that a patient may accept or refuse. We will discuss the following in this chapter: (1) The ethical principle of respect for the autonomy of the patient; (2) the legal, clinical, and psychological significance of patient preferences; (3) informed consent; (4) decisional capacity; (5) truth in medical communication; (6) cultural and religious beliefs; (7) refusal of treatment; (8) advance directives; (9) surrogate decisions; (10) the challenging patient; and (11) alternative medicine.

The Principle of Respect for Autonomy

Respect for autonomy is the guiding ethical principle of the Topic of Patient Preferences. Respect for autonomy is one aspect of a larger principle, namely, respect for persons, which is a fundamental principle of all morality. Respect for persons affirms that each and every person has moral value and dignity in his or her own right. In this sense, the principle of respect applies to every encounter between persons, including those between a physician and a patient. One implication of respect for persons is a respect for personal autonomy, that is, acknowledging the moral right of every individual to choose and follow his or her own plan of life and actions.

In clinical ethics, respect for the autonomy of the patient signifies that physicians' judgments about how to benefit their patients should never ignore or override the preferences of those patients. Patients have the right to freely accept or reject physician's recommendations. Their response to the physician's recommendations should reflect their own values for their own lives. The physician must be confident that medical interventions are acceptable to the patient. As a moral principle, respect for autonomy is a “two-way street”: the autonomy of physicians to act only on their best judgment about how best to benefit a patient medically, must also be respected. Therefore, respect for patient autonomy does not imply that patients have the right to demand inappropriate treatment, or that a physician must accede to any and every request of a patient if it conflicts with the physician's best judgment.

While physicians must always respect the autonomy of their patients, in practice, many forces may obstruct and limit the ability of patients to express their preferences. In clincal ethics, respect for patient preferences takes place within a therapeutic relationship, that is, when some health problem prompts a patient to seek help ...

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