The term autonomy originates from the Greek roots “self” and “rule” and, when applied to the medical sphere, registers a patient’s right to self-determination. This principle derives from the societal respect for an ill individual who is making an informed decision regarding treatment (or refusing treatment). Further, the concept of autonomy underlies the increased use of advance directives (written instructions, such as a living will or durable power of attorney , which provide direction if the patient’s decision-making capacity is impaired) in today’s practice of medicine, including psychiatry. As will be discussed later in this chapter, the psychiatric consultant is frequently asked to evaluate a patient’s capacity to make decisions regarding treatment, especially as the cognitive processes underlying that capacity can be impaired by various neuropsychiatric conditions (e.g., dementia, delirium , intoxication, schizophrenia, etc.). As such, this evaluation directly relates to the ethical principle of autonomy . However, unless a clear advance directive from the patient, prior to illness, exists, he will generally be treated in accordance with his best interests, an ethical issue relating to the balance of autonomy and beneficience (discussed below).

Beneficence refers to the physician’s obligation to help others and to promote the patient’s welfare. In other words, this ethical pillar directs treating physicians, treatment-team members, and consultants to act in the best interests of their patients, and considers that patients—because of medical or psychiatric conditions—represent a particularly vulnerable group who rely on the physician’s guidance. This principle further requires physicians to “put the interests of their patients ahead of their own or those of third parties, such as insurers or managed care organizations” (Pantilat and Lo 2005).

This ethical principle is derived from the Latin primum non nocere , or first, do no harm, and stems from the Hippocratic Oath , which states, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them” (Schetky 2007). Nonmaleficence serves to remind physicians and treatment-team members to carefully consider the adverse effects associated with treatments and is commonly seen as a corollary to beneficence .

Simply put, justice guides the physician in how to treat “similarly situated patients similarly and [to] allocate resources fairly” (Pantilat and Lo 2005). This principle ensures that patients receive equal care regardless of demographic, sociocultural, economic, and psychological differences. To assure that actions are “just,” interventions should be based on standards of care that can be applied to society as a whole. This principle is also of relevance in our current economy, as many facilities and hospitals face limited healthcare resources, bringing to bear the necessity of practicing cost-effective medicine.