Patients' autonomy and medical benefit: ethical reasoning among GPs

Background. During the last decades, the traditional role of GPs as decision-makers for their patients has been questioned. Objectives. The aim of this study was to identify and discuss how GPs deal with and how they reason in situations where there is a possible tension between the obligation to respect the patients' right to self-determination and the obligation to promote their health. Methods. One hundred and twenty randomly selected Swedish GPs received a mailed questionnaire with two vignettes, one describing a patient reluctant to have a medically motivated intervention, the other describing a patient requesting a medically doubtful intervention, Forty seven of these GPs subsequently were interviewed by telephone. Results. With regard to the first vignette, approximately two-thirds of respondents to the questionnaire (n = 82) answered that they would not accept the patient's reluctance. Older GPs were somewhat more inclined to try to persuade the patient to come to their surgery than were younger colleagues. In the interview most respondents answered that the right to self-determination ought to be given priority, but the obligation to promote health had a greater influence on their behaviour. Regarding the second vignette, two-thirds of respondents to the questionnaire answered that they would not give way to the patient's request for intervention. Younger GPs said "No" more often than did their older colleagues. In the interviews, justifications for their response referred to medical benefit, uneasy patients, self-protection and justice. Conclusion. When facing such conflicts in everyday practice, the ethical codes of medicine are often too categorical to give any guidance. The situational ideal of covenant would be more helpful, and ought to be emphasized by medical teachers as well as tutoring older colleagues.