Today’s question arises from increased public health demands. My correspondent has:

… a question about a security staff member at an airport ignoring the passenger’s request to be temperature tested at the anterior wrist as opposed to “the company policy” for which she could not provide documentation of, saying she must take the temperature behind the ear. I was behind the passenger and heard her emphatically state she did not want to be temperature tested behind her ear but offered her anterior wrist. As a Paramedic, I know the wrist gives a reading and so did the passenger being tested. The chartered plane security guard refused to test at the wrist even when the passenger spoke to her about autonomy. She would not allow the passenger on the plane without being tested behind the ear. The passenger ended up conceding but was clearly distressed at her autonomy being disregarded. When laypeople are given roles to temperature test, why are they not given the understanding of autonomy? Is there documentation I can provide this security person should I see her again, which is likely as I travel there often. Autonomy is such an important ethical and legal issue.

Respect for autonomy is indeed an important and ethical legal issue and one of Beauchamp and Childress’ ‘Principles of Biomedical Ethics’ (a reference to a seminal textbook on the subject). In the context of medical and paramedical practice, respect for autonomy means health care practitioners have to respect a patient’s own choices and decisions even if the practitioner does not think they are wise choices. Health practitioners as patient advocates may even advocate for the patient’s wishes where what the patient wants is not ‘company policy’.

I’ll give an example using my own jurisdiction. Here in the Australian Capital Territory (the ACT) there are two hospitals with public emergency departments, Canberra Hospital on the south side (ie south of Lake Burley Griffin) and Calvary Hospital on the north side. Paramedics may be treating a person on the south side so Canberra Hospital would be the ‘normal’ destination – if you like the ‘policy’ destination; but the patient may live on the north side and prefer to go to Calvary as that is closer to home and family and therefore their social support. A paramedic may want to advocate for their patient’s choice – talk to co-ord and ask -even argue – to take the patient to Calvary. That would show respect for patient autonomy and other ethical principles may also come to play. In particular the principle of ‘beneficence’ that is it would actually benefit the patient to go to Calvary. But there may be circumstances where it would not benefit the patient. The extra time that it would take may be critical given their condition so the principle of non-maleficence (ie do no harm) says take the person to the Canberra hospital. It may be a busy night and tying up an emergency ambulance by the longer drive to Calvary and then to return to the south side may reduce the service to others so the principle of ‘justice’ would say go to Canberra.  The point is that the patient’s wishes are not the only factor to be considered. The patient can refuse to go to Canberra, can ask to go to Calvary, but cannot insist to go to Calvary even though ACT Ambulance regularly transport patients to both hospitals.

Take a more extreme example, the patient may, for similar reasons, say that they actually want to go to the Royal Prince Alfred Hospital (RPAH) in Sydney.  And even if that would be of some benefit to the patient the ACT Ambulance Service could well say ‘that is not an option’; no matter how much the patient wants it and no matter how much it would advance their autonomy to be taken to the RPAH, ACTAS does not transport emergency patients from Canberra to Sydney just because the patient wants to go there.

Let us consider another example. This time the patient agrees to go to the nearest hospital but says ‘but there’s a social function I promised to go to and it’s very important to me, so I’ll go there first and then go to the hospital’. Respect for patient autonomy means the paramedics cannot override the patient’s choice – they can give advice on why that is a bad choice, but they cannot compel the person to come with them. But they can refuse if the person says ‘can you give me a lift to the social function and stay with me to make sure I’m ok, and then drive me to hospital?’ They can refuse as that would be facilitating the poor choice but equally because that is not a service we offer. A doctor can respect a patient’s choice to smoke, but they do not have to condone it or buy them cigarettes.

What’s the relevance of all that? Respect for autonomy means respecting a person’s choices. For health professionals, the patient is their client or person of primary concern, so they may want to advocate to achieve the patient’s autonomous wishes. But there are limits. They are not required to do what the patient wants (no matter how far that would advance their autonomy) if they do not think it is in the patient’s best interests. Nor are they required to provide the service the patient wants if other principles point to an alternative outcome and in some cases because it’s just beyond the scope of what they can offer.

Where does that put our security guard? I assume that the security guard is not a paramedic or other health professional (of course they might be working a 2nd job, but I’ll assume that’s not the case). First her ‘client’ is not the patient, it’s the airline or airport that have engaged her employer’s services. I think we can safely assume that she’s probably been trained ‘this is how you take the temperature’. The paramedic (my correspondent) and the passenger may know the ‘anterior wrist’ can also be used to take the temperature, but the security guard may not. And no doubt the security guard does not want to act on what the passenger says and then be the person on the news for failing to apply the training they have been given. Taking the temperature at the wrist, rather than behind the ear, like driving a patient to their social function and waiting for them, was simply not a service on offer.

Justice requires the fair allocation of resources. The security guard has to process everyone who wants to get on the plane.  There are costs in delaying flights to ask questions of superiors (‘can I take a temperature at the wrist?’) or to argue with the passenger. The security guard (again I assume) does not know whether there is harm to anyone else if she takes the temperature at the wrist. What if the wrist temperature would be lower than behind the ear so the temperature taken reads at the top of the acceptable range but if taken at the ear would read higher and flag that the patient should not fly? I don’t know if that is possible, and I bet the security guard doesn’t either. But her job is to screen the passengers for everyone’s benefit, not just or even the individual passenger being screened. Unlike a paramedic treating a patient, the passenger’s autonomy is not her primary concern. Her job is concerned with the well-being of the entire flight. Justice says you get screened behind the ear, like everyone else.

But respect for autonomy is not irrelevant. The passenger’s choices have to be respected. If she does not want to be tested behind the ear, or go through a metal detector, or put her carry-on luggage on the machine for inspection, that is indeed her right and choice and it should be respected. Exercising your rights is not however cost free. A person may choose to smoke but that comes with the cost of an increased risk of many diseases. A person may choose not to be subject to airport screening the cost of which is that they don’t get on the plane. Respect for autonomy is to allow them that choice and to respect their choice; it does not compel the airline or the security to offer an alternative.

Telling the passenger that she would not be allowed ‘on the plane without being tested behind the ear’ is respecting her autonomy. Telling a person what the consequence of their choices are but still leaving it to them to make a choice – an informed choice – is respecting autonomy.

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