Assessing autonomy in psychiatric practice: a narrative literature review

This article's "Key Question" is: Does enforcing treatment restrict a person's autonomy, or is their mental illness their source of autonomy restriction with treatment seeking its restoration? While autonomy assessments occur in manifold contexts, distinguishing autonomy-undermining from autonomy-promoting influences can be difficult. This narrative literature review aims to conceptualise autonomy in a clinically useful way. Its construction is guided by the Scale for the Assessment of Narrative Review Articles and the Narrative Overview Rating Scale. 126 journal articles, 11 peer-reviewed encyclopaedia articles, and 2 classic bioethical book chapters are reviewed. Autonomy is defined as "self-governance". Clinical and ethical utility lies in assessing autonomy's dimensions of "self" and conditions of "governance". These are: personal identity, liberty, relatedness, agency, decisional capacity, coherence, desire-orders, authenticity and temporality, further classifiable as procedural or substantive accounts of autonomy. Paternalism may not always conflict with autonomy. The Key Question is an ethical and clinical prism through which these various refractions of autonomy are examined and rendered usable. Autonomy ambiguities and conflicts are identified, along with contexts and patient presentations which may recommend that their autonomy assessment and Key Question answer lean towards one direction or the other, depending on the patient's unique evolving formulation. Through synthesising the broad interdisciplinary autonomy literature and its Key Question applications, this twelve-factor framework is offered to assess and enhance patient autonomy. Ultimately, it is hoped that in applying this framework to their own lived experience, people with mental illness might be empowered to expand awareness of their self and self-sovereignty.