The meaning of autonomy in medicine

By Roger Collier | CMAJ | Aug. 22, 2016

“How long are we going to have autonomy if we don’t start to take responsibility for some of the things we are seeing in the health care system?” asked Kimberly Williams, president of Resident Doctors of Canada. (Mark Holleron/CMA)

At first, the discussion focused on the importance of physician autonomy. Then it shifted to a question: what exactly do we mean by “autonomy” in medicine? Finally, near the end of the discussion, one physician made a suggestion: let’s use another word.

“Could we consider replacing the word ‘autonomy’ — it flies in the face of what we have been talking about: collaboration, integration, teamwork, et cetera — and consider the word ‘responsibility’?” Dr. Jasneet Parmar of Alberta  asked today at a session on emerging issues in health at the annual meeting of the Canadian Medical Association (CMA).

Indeed, it is time to “elevate the conversation,” suggested Dr. Joanne Sivertson of Saskatchewan. “We really, really need to define ‘autonomy’” she said, noting that freedom from undue influence is not the opposite of teamwork.

Some physicians, however, appeared pretty comfortable with the word “autonomy,” stating that it was a pillar of the medical profession. Independence is what permits physicians to put their patients’ needs first, they argued. “As more physicians are being told where to practise, how to practise and what services to provide, there are concerns that the autonomy of the physician as an independent contractor and patient advocate is being significantly eroded,” said Dr. David Milne of Nova Scotia.

How a physician is paid can also affect their independence, some argued. This is the case in the North West Territories, where physicians are given salaries by the government, noted Dr. Ewan Affleck of Yellowknife. As employees, physicians have a duty to their employer and must adhere to a code of ethics. Yet they also have a duty to their patients. “At times, they are in conflict,” said Affleck.

Others noted that medical officers of health, and many other public health physicians, are also employed by provincial or territorial governments. And when their advocacy work on behalf of the public conflicts with government agendas, there is the risk of political interference.

“Unfortunately, examples of this are not rare in Canada,” noted Dr. Austin Zygmunt of Nova Scotia, who stressed the importance of public health legislation to protect advocacy work.

As more physicians are being told where to practise, how to practise and what services to provide, there are concerns that the autonomy of the physician as an independent contractor and patient advocate is being significantly eroded

For the profession as a whole, however, the focus on payment structures may be misguided, suggested Dr. André Bernard, an observer from Nova Scotia. “It goes well beyond being independent contractors,” said Bernard. “I would draw caution that we do not bite our nose off to spite our face just in the name of a physician financing system that may be archaic and may need to change in certain contexts and certain jurisdictions in Canada.”

It is important for physicians to remember that the professional autonomy they enjoy is a privilege granted in exchange for their responsibilities to society, noted Dr. Yun Jen, president of the Québec Medical Association. “We are talking about a social contract here,” she said (through a translator). If the medical profession is losing its autonomy, she suggested, it may be because it has failed in its collective responsibility to society.

Dr. Kimberly Williams, president of Resident Doctors of Canada, also pointed to the bigger picture. Autonomy allows physicians to be leaders, she said, and that comes with a responsibility to take action to help create a sustainable health care system. “How long are we going to have autonomy if we don’t start to take responsibility for some of the things we are seeing in the health care system?”

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