[The donkey bridge of patient autonomy in psychiatry]

In bioethics, patient autonomy is often considered a fundamental principle, even more important than beneficence, non-maleficence and justice. Inspired by liberal philosophies (such as J.S. Mill) and the morality of duty (especially Kant), this principle recognizes human dignity and the right of each individual to make free decisions about their health. In practice, this means that health professionals are obliged to provide patients with clear information and obtain their informed consent, while respecting professional confidentiality. In psychiatry, however, this principle is particularly challenging. Mental disorders can affect patients' capacity to make decisions, thereby compromising their autonomy. Delicate situations arise when a psychotic or severely depressed patient refuses necessary care. Carers then face an ethical dilemma: should they impose treatment 'for the good' of the patient, at the risk of adopting a paternalistic approach that is now frowned upon? This dilemma reveals a tension between individual autonomy and the reality of human vulnerability. Some ethicists propose a more relational approach to autonomy, in which the patient's choices are supported by those around him and by carers, creating a framework in which autonomy is exercised in interdependence. From this perspective, helping patients does not negate their autonomy, but rather supports it. Finally, in psychiatry, respect for autonomy must be nuanced, allowing in some cases the use of restricted care to protect the fundamental interests of the patient and those around him or her.