Abstract
The notion of respect for autonomy dominates bioethical discussion, though what qualifies precisely as autonomous action is notoriously elusive. In recent decades, the notion of autonomy in medical contexts has often been defined in opposition to the notion of autonomy favoured by theoretical philosophers. Where many contemporary theoretical accounts of autonomy place emphasis on a condition of “authenticity”, the special relation a desire must have to the self, bioethicists often regard such a focus as irrelevant to the concerns of medical ethics, and too stringent for use in practical contexts. I argue, however, that the very condition of authenticity that forms a focus in theoretical philosophy is also essential to autonomy and competence in medical ethics. After tracing the contours of contemporary authenticity-based theories of autonomy, I consider and respond to objections against the incorporation of a notion of authenticity into accounts of autonomy designed for use in medical contexts. By looking at the typical problems that arise when making judgments concerning autonomy or competence in a medical setting, I reveal the need for a condition of authenticity—as a means of protecting choices, particularly high-stakes choices, from being restricted or overridden on the basis of intersubjective disagreement. I then turn to the treatment of false and contestable beliefs, arguing that it is only through reference to authenticity that we can make important distinctions in this domain. Finally, I consider a potential problem with my proposed approach; its ability to deal with anorexic and depressive desires.
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Notes
Hierarchical theories of autonomy are sometimes thought to require explicit reflection on the basis of second-order desires, but this is something proponents of hierarchical theories sought to avoid (see Frankfurt 1971; Dworkin 1988). I will thus focus on correspondence rather than reflective acceptance in what follows.
For an account of the various problems faced by hierarchical theories of autonomy, and the various ways that subsequent theories of autonomy have been developed to avoid these problems (see Taylor 2005).
As will be further elucidated below, Faden and Beauchamp want their account of autonomy to be focused on actions, not persons. It is for this reason that they speak of an action being autonomous, rather than, as is more common in the theoretical literature, a person being autonomous with respect to her action.
More on this distinction below.
Again, we will look at this in more detail below.
I use the term “intersubjective” rather than “external” or “objective” here and in what follows because I want to stress that there is no objective standard by which the content of someone’s values and goals can be criticized—when we criticize the content of others’ values and goals, we are doing so from our own conception of rationality, wellbeing, etc., or from standards that have achieved widespread intersubjective agreement in our society (see Wolf 1987).
This approach might also show promise for Faden and Beauchamp’s condition of noncontrol—they themselves suggest that a condition of authenticity shows the most promise when it comes to adequately capturing both external and internal controlling influences (1986). However, an adequate assessment of this complicated concept is beyond the scope of this paper.
The so-called “Gettier Problem” reveals just how vexing some of these issues can be (see Gettier 1963).
Faden and Beauchamp also provide a third example here: “Nothing good can come of my consenting to this procedure, because no matter what new skills and coping styles I might develop, I will never want to live as a quadriplegic.” This is a particularly difficult case, and one that has attracted considerable attention in the existing literature (see, e.g., Savulescu 1994; Cowart and Burt 1998). Without getting into the details of this nuanced issue, I believe such a case can be satisfactorily dealt with by my proposed approach, by first making an effort to dispel unrealistically negative conceptions of what it means to be a quadriplegic (see Savulescu 1994), but, after reasonable efforts have been made, accepting the patient’s decision to refuse treatment on the basis of his enduring values.
This need not fundamentally change the purpose of autonomy or competence requirements; we could view these decisions as prima facie worthy of special respect and protection, but able to overridden in exceptional circumstances. Indeed, this is the role that Faden and Beauchamp envision for autonomous decisions.
Many thanks to Dietmar Hübner and two anonymous referees from the HEC Forum for their useful comments on an earlier draft of this paper.
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White, L. The Need for Authenticity-Based Autonomy in Medical Ethics. HEC Forum 30, 191–209 (2018). https://doi.org/10.1007/s10730-017-9335-2
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DOI: https://doi.org/10.1007/s10730-017-9335-2