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Open Access Highly Accessed Research article

Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care

Veikko Pelto-Piri12*, Karin Engström3 and Ingemar Engström12

Author Affiliations

1 Psychiatric Research Centre, Örebro County Council, Box 1613, SE 701 16, Örebro, Sweden

2 School of Health and Medical Sciences, Örebro University, SE 701 82, Örebro, Sweden

3 Department of Child and Youth Studies, Stockholm University, Frescati Hagväg 24, SE 106 91, Stockholm, Sweden

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BMC Medical Ethics 2013, 14:49  doi:10.1186/1472-6939-14-49

Published: 6 December 2013



Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.


All staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.


The majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.

Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.

Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.

Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.


Paternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

Staff; Psychiatric care; Paternalism; Autonomy; Reciprocity; Qualitative theory-guided content analysis; Diary method; Ethical considerations; Ethical issues