Broadening the ethical focus: a community perspective on patient autonomy

Health care ethics has a 'cultural' bias that is patterned on the organizational culture of our health care system. The ethical issues that are identified and debated within our institutions often are shaped by this organizational culture, and as with any culture to which one has been socialized, its influences remain, to a large extent, indistinct and unrecognized. In the field of health care ethics, these influences can direct teaching, regulate common practices, and determine what is or is not considered to be an ethical issue. The movement of health care outward from the hospital into the community provides an opportunity to explore some of the unexamined assumptions that guide our ethical deliberations. By stepping outside of the hospital culture and viewing ethical issues from a community perspective, the authors examine some of the presumptions and beliefs that lie beneath the usual institutional approach to respecting patient autonomy. Two case stories provide concrete examples of how institutional traditions can direct ethical practice.