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Institute of Biomedical Ethics and History of Medicine (IBME)

Dissertation Ana Rosca

Patient autonomy and quality of care


This thesis proposes an integrative approach over three important bioethical aspects.

Respect for patient autonomy is one of the most important values of biomedical ethics. This thesis proposes that this value should be implemented not only on an individual level, but also on an organizational and policy level. Respect for patient autonomy was long discussed in the context of individual patients and how it can influence the decision-making outcome depending on how well it is implemented. Implementing patient autonomy at the organizational level may strengthen its implementation. By promoting respect for patient autonomy at the national and policy level, it might help develop a new societal culture in which the patient becomes an equally strong stakeholder in decision-making process related to healthcare systems. This holistic approach is necessary to ensure a successful and sustainable implementation of respect for patient autonomy as a general value in all healthcare related initiatives.

For this to become feasible it important to create collaborative relationships between initiatives that follow a similar aim. Both biomedical ethics and improving quality of care and patient safety initiatives share the same overarching goal – improve the experience and the well-being of patients during and after a treatment. This thesis proposes to discuss this goal from both the ethical and quality of care perspective, and encourages promoters on both sides to join their know-how and experience to find more efficient and timely approaches in reaching this common goal.

A third integrative approach discussed in this thesis is the combination of advance care planning (ACP) and shared decision making (SDM) within one continuous process. The two concepts have been approached and discussed by distinct research groups in distinct contexts, which has built a conceptual gap in the existing literature and research. However, as both ACP and SDM were designed to support patients with important decisions for the immediate and future care, integrating the two concepts into once single process might ensure a true goal concordant and informed treatment choice.

The many barriers that act as gatekeepers in the implementation of patient autonomy promoting initiatives may be overcome by ensuring an integrative approach at individual, organizational and policy level. As medicine happens at the intersection of humanitarianism, research and economy, only initiatives designed to respond to the needs of each of these dimensions might have a chance at succeeding in creating a culture in which respect for patient autonomy is a priority.