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Overvaluing autonomous decision-making

  • Peter Lepping (a1) and Bevinahalli Nanjegowda Raveesh (a2)

Current capacity-based legislation and practice overvalues autonomy to the detriment of other ethical principles. A balanced ethical approach would consider the patient's right to treatment, their relationships and interactions with society and not solely the patient's right to liberty and autonomous decision-making.

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Corresponding author
Professor Peter Lepping, Centre for Mental Health and Society, Wrexham Academic Unit, Betsi Cadwaladr University Health Board, Technology Park, Croesnewydd Road, Wrexham LL13 7YP, UK. Email:
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2 Berlin, I. Four Essays on Liberty. Oxford University Press, 1969 (reprint 2004).
3 Beauchamp, T Childress, J. Principles of Biomedical Ethics (5th edn). Oxford University Press, 2001.
4 Bloch, S Green, SA. An ethical framework for psychiatry. Br J Psychiatry 2006; 188: 712.
5 Carson, AM Lepping, P. Ethical psychiatry in an uncertain world: conversations and parallel truths. Philos Ethics Humanit Med 2009; 4: 7.
6 Burns, T Yeeles, K Molodynski, A Nightingale, H Vazquez-Montes, M Sheehan, K et al. Pressures to adhere to treatment (‘leverage’) in English mental healthcare. Br J Psychiatry 2011; 199: 145150.
7 Owen, GS David, AS Hayward, P Richardson, G Szmukler, G Hotopf, M Retrospective views of psychiatric in-patients regaining mental capacity. Br J Psychiatry 2009; 195: 403407.
8 Lepping, P. Overestimating patients' capacity. Br J Psychiatry 2011; 199: 355356.
9 Pylee, MV. Constitutional Government in India. Chand & Co, 2004.
10 Shah, R Basu, D. Coercion in psychiatric care: global and Indian perspective. Indian J Psychiatry 2010; 52: 203206.
11 Srinivasan, TN Thara, R. At Issue: management of medication noncompliance in schizophrenia by families in India. Schizophr Bull 2002; 28: 531535.
12 Rajkumar, AP Saravanan, B Jacob, KS Voices of people who have received ECT. Indian J Med Ethics 2007; 4: 157164.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Overvaluing autonomous decision-making

  • Peter Lepping (a1) and Bevinahalli Nanjegowda Raveesh (a2)
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letter to editor

PAUL CRICHTON, consultant psychiatrist
07 March 2014

The editorial by Lepping and Raveesh (1) makes the very good point that, while autonomous decision-making is important, autonomy does not automatically trump other values which also need to be taken into consideration. They note that patients can benefit from the help provided by social and family relationships, even if this goes against the wishes of these patients.

But one way of reconciling, at least partly, this apparent conflict between the autonomy and the best interests of patients, as realized through social relationships, is to argue for a relational or social conception of autonomy, rather than for a more purely individualistic conception (2). The basis of this is the fact that human beings are socialcreatures to the core, and that they are partly constituted by their relations to other people. We form our own desires and opinions in the first place by "steadying our minds" in "trustful conversation" with others, as the philosopher, Bernard Williams (3) has pointed out. In thissense social relations are built into personal autonomy from the very beginning.

1 Lepping, P. and Raveesh, B.N. Overvaluing Autonomous Decision-Making, Br J of Psychiatry, 2014, 204, 1-2.

2 Crichton, P. Self-Realization and Inner Necessity Thinking About How to Live, London and Munich: Kiener Press (

3 Williams, B.A.O. (2002) Truth and Truthfulness An Essay in Genealogy, Princeton: Princeton University Press.

Paul Crichton, Ministry of Justice, London, UK ( Greer, St Raphael's Hospice, Cheam, Surrey, UK

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Conflict of interest: None declared

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Respecting Autonomy; A Means, Not An End

Vincent Riordan, Consultant Psychiatrist
07 February 2014

Lepping and Raveesh's critique of the emphasis placed on autonomy in mental health care is to be welcomed (1), indeed it could be argued that the problems with autonomy are understated.

Implicit in framing the debate in terms of autonomy being favoured disproportionately over "other ethical principles" is the acceptance of the idea that autonomy has some intrinsic ethical value in the first place. Once such an idea is accepted, conflict with other ethical principles becomes inevitable. However, as the authors point out, assessing ethical values a priori is problematic, but, as David Hume observed, so too is deriving them empirically (2). Thus any conflict between competing ethical principles seems un-resolvable.

An alternative approach might be to regard respect for autonomy merely as a means to the end of beneficence. Beneficence, or to use Carson and Lepping's term "helping people"(3) is, after all, the traditional goal of healthcare. If beneficence is regarded as the primary ethical value, then the autonomy-paternalism debate simply becomes a pragmatic one about how best to achieve the beneficent goal. More often than not autonomy may be the more appropriate "tool" and well meaning paternalism may well have resulted in much harm in the past (4), (and thushas the potential to continue to do so), but such observations merely demonstrate the utility value of autonomy, but not it having any intrinsicethical value.

In most clinical settings this distinction between intrinsic ethical value and utility value doesn't appear to matter because we tend to becomeaware of different values only when they conflict (5). However, where a conflict between autonomy and beneficence does occur, to favour autonomy over beneficence would be to fail to act in what we believe to be our patients' best interests. This would create the opportunity for other interests to be served, interests which may not necessarily be benign, or even claim to be. It would seem na?ve not to consider the possibility that this may serve the interests of those best placed to influence publicpreferences and choices, namely those in a position to utilise the tools of the advertising industry, a large and pervasive industry with the specific aim of manipulating such preferences and choices. To confer intrinsic ethical value on autonomy is to confer intrinsic legitimacy on whatever people can be persuaded to want or choose, thus reinforcing the power of those with the resources to fund the persuading. This raises thesomewhat unsettling possibility that autonomy divorced from beneficent paternalism, which is promoted by many in the recovery movement as being the route to empowerment (4), could be used as an instrument of control.

Respect for autonomy is a useful tool which historically has been underutilised, but it is no more than that. Elevating it to the status ofintrinsic ethical principle merely serves to exempt it from critical appraisal.

Dr Vincent Riordan MRCPsychConsultant PsychiatristWest Cork Mental Health ServicesBantry, County Cork, Ireland

1.Lepping P, Raveesh BN. Overvaluing autonomous decision-making. BrJ Psychiatry 2014; 204:1-2.

2.Hume D. Moral Distinctions not derived from reason: In A Treatiseof Human Nature: Book III, part I, section I, 1739.

3.Carson AM, Lepping SA. Ethical psychiatry in an uncertain world: conversations and parallel truths. Philos Ethics Humanit Med 2009; 4:7.

4.Slade M. Empowerment Rationale. In Personal Recover and Mental Illness, A Guide for Mental Health Professionals: 69-73. Cambridge University Press, 2009.

5.Fulford, KWM. Ten principles of values-based medicine (VBM). In Philosophy and Psychiatry (Ed. T Schramme and J Thome): 50-83. De Gruyter GmBH, Berlin, 2004.

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Conflict of interest: None declared

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"Dare-to-care stance" to avoid patient abandonment

Oliver Freudenreich, Medical Director, MGH Schizophrenia Program
27 January 2014

Dear Sir:Lepping and Raveesh's editorial "Overvaluing autonomous decision-making" in this journal (January 2014)1 is a welcome reminder that autonomy is butone ethical principle guiding physicians and society. To their discussion, we would add that substantial harm in the form of patient abandonment can stem from an overemphasis on autonomy. When rights-based frameworks are overemphasized, autonomy can be used as an ethical trump card to avoid what might be perceived as coercion or paternalism. However, an unforeseen and often unnoticed consequence of playing this card can be patient abandonment. This is a particular problem in serious mental illness (SMI), where an unrecognized deficit in executive autonomy2may contribute to ill-considered decisions that are nonetheless respected in systems where patient rights are lionized and the exercise of physicianauthority is discouraged.3 Families who care for somebody with SMI are frequently left fending for themselves if their loved one's short-term decisional autonomy is kept in the foreground and deficits in executive autonomy are ignored. In many such cases, either no treatment is providedor the treatment of SMI occurs in non-medical settings (e.g., prisons or homeless shelters).

The World Health Organization's slogan devised to counter stigma, "dare-to-care," could be appropriated as a pithy ethical principle for clinicians, empowering them to dare to actually provide (or at least push for) appropriate medical care, even in settings biased toward autonomy. It would remind physicians that truly caring for the welfare of patients with SMI means not too readily playing the autonomy card as a default but equally considering other ethical principles and obligations; it would serve as a reminder to resist anticipatory obedience ("the patient does not fulfill commitment criteria") but, as Lepping and Raveesh state, to try and actually help people. The dare-to-care stance does not stand in opposition to autonomy but could be viewed as a categorical imperative formedical decision making that allows for the consideration of many ethical principles, including autonomy.

Oliver Freudenreich, MDMedical Director, MGH Schizophrenia Program

Nicholas Kontos, MDDirector, Transplantation Psychiatry

John Querques, MDCo-Associate Director, Psychosomatic Medicine Fellowship Program

All authors are at Massachusetts General Hospital,Boston, Massachusetts, USA


1Lepping, P and Raveesh BN. Overvaluing autonomous decision-making. The British Journal of Psychiatry 2014; 204:1-2.

2Naik AD, Dyer CB, Kunik ME, et al. Patient autonomy for the management of chronic conditions: a two-component re-conceptualization. The American Journal of Bioethics 2009; 9:23-30.

3Kontos, N, Freudenreich O, Querques J. Beyond capacity: identifyingethical dilemmas underlying capacity evaluation requests. Psychosomatics 2013; 54:103-110.

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Conflict of interest: None declared

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