George Agich

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does. Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power.

Objective: We hypothesized that the reasons behind this tension are complex and can be understood better by applying social psychology theory.Design: A qualitative methodology was drawn on for data collection and thematic analysis, with focus group discussions adopted for interviews with patient families and ICU physicians. Additionally, we used a social psychology theory, the reasoned action approach (RAA) framework, to understand these tensions.Setting: Two 15-bedded ICUs of an academic university–affiliated teaching hospital in Singapore.Subjects: A total of 72 physicians and family members of older ICU patients (>70 years old).Measurements and Main Results: The primary analysis revealed five areas of tension around prognostication in the ICU. These dealt with issues of divergent views, different role expectations, conflicting emotional responses, and issues of communication and trust. Further analysis helped to identify underlying factors leading to tensions and behaviors. Differences in prognostication and in expectation of outcomes between clinicians and family members were the main cause of tensions. When the RAA framework was applied, these tensions could be predicted early on and understood more clearly.Conclusions: Tensions revolve around losing control of the patient’s care, differences between hopeful expectations and clinical prognostication, perceived biases of physicians, and underlying mistrust between families and physicians.

Respecting the autonomy of disabled people is an important ethical issue for providers of long-term care. In this influential book, George Agich abandons comfortable abstractions to reveal the concrete threats to personal autonomy in this setting, where ethical conflict, dilemma and tragedy are inescapable. He argues that liberal accounts of autonomy and individual rights are insufficient, and offers an account of autonomy that matches the realities of long-term care. The book therefore offers a framework for carers to develop an ethic of long-term care within the complex environment in which many dependent and aged people find themselves. Previously published as Autonomy and Long-term Care, this revised edition, in paperback for the first time, takes account of recent work and develops the author's views of what autonomy means in the real world. It will have wide appeal among bioethicists and health care professionals.