Más allá de la toma de decisiones: Una visión contextual y multidimensional de la autonomía del paciente

Abstract

There has been a trend in the clinical literature to reduce patient autonomy to decision-making, perhaps due to the influence of the philosophical-legal tradition and because of its initial hospital and emergency medicine focus. This paper presents a broader model of autonomy, which, in addition to strict medical issues and respect for freedom of choice, pays more attention to the specificities that characterise people in need of health care, i.e., the biological, psychological, and social aspects that allow or impede them a greater degree of autonomy. To that end we identify and describe all the stages or points at which the question arises of the patient's (in)capacity for self-management throughout the care process. This generates a more complex and multidimensional notion of patient autonomy which, in addition to the ability to make free and therapeutically informed decisions —decisional autonomy—, also includes the ability to carry out basic vital functions and tasks that can be performed by a statistical majority of people (such as eating, seeing, walking, understanding complex situations, etc.) —functional autonomy—, the patient's capacity to plan, sequence, and perform tasks related to the management of their chronic diseases, i.e., the capacity to implement the chosen therapeutic plan and maintain it over time—executive autonomy—, the patient's capacity to retain, understand and communicate coherently and understandably for others the principle identifying aspects that have characterised them during their lives—narrative autonomy—, and the ability of patients to access and control information relative to their situation for themselves—informative autonomy—.