Medicine, Health Care and Philosophy

, Volume 4, Issue 2, pp 185–192 | Cite as

Autonomy and dependence: Chronic physical illness and decision-making capacity

  • Wim J. M. Dekkers


In this article some of the presuppositions that underly the current ideas about decision making capacity, autonomy and independence are critically examined. The focus is on chronic disorders, especially on chronic physical disorders. First, it is argued that the concepts of decision making competence and autonomy, as they are usually applied to the problem of legal (in)competence in the mentally ill, need to be modified and adapted to the situation of the chronically (physically) ill. Second, it is argued that autonomy and dependence must not be considered as two mutually exclusive categories. It is suggested that decision making may take on the form of a more or less conscious decision not to be involved in making all kinds of explicit and deliberate decisions. Elaborating on Agich's distinction between ideal and actual autonomy, the concept of “Socratic autonomy” is introduced.

autonomy chronic illness decision making capacity dependence multiple sclerosis 


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  1. Agich, G.J.: 1993, Autonomy and Long–Term Care. New York/Oxford: Oxford University Press.Google Scholar
  2. Agich, G.J.: 1995, 'Actual Autonomy and Long–Term Care Decision Making', in: L.B. McCullough and N.L. Wilson (eds.), Long–Term Care Decisions. Ethical and Conceptual Dimensions. Baltimore/London: The Johns Hopkins University Press, pp. 113–136.Google Scholar
  3. Beauchamp, T.L. and J.F. Childress: 1994, Principles of Biomedical Ethics. New York/Oxford: Oxford University Press.Google Scholar
  4. Brody, H.: 1987, Stories of Sickness. New Haven and London: Yale University Press.Google Scholar
  5. Buchanan, J.H.: 1991, Patient Encounters. The Experience of Disease. New York: Henri Holt and Company.Google Scholar
  6. Bury, M.R.: 1982, 'Chronic Illness as Biographical Disruption', Sociology of Health and Illness 4, 167–182.PubMedCrossRefGoogle Scholar
  7. Callahan, D.: 1993, The Troubled Dream of Life. Living with Mortality. New York etc.: Simon & Schuster.Google Scholar
  8. Charmaz, K.: 1983, 'Loss of Self: A Fundamental Form of Suffering in the Chronically Ill', Sociology of Health and Disease 5, 169–195.Google Scholar
  9. Collopy, B.J.: 1995, 'Safety and Independence: Rethinking Some Basic Concepts in Long–Term Care', in: L.B. McCullough and N.L. Wilson (eds.), Long–Term Care Decisions. Ethical and Conceptual Dimensions. Baltimore/London: The Johns Hopkins University Press, pp. 137–154.Google Scholar
  10. Dekkers, W.J.M.: 1995, 'Chronicity and the Lived Body in Multiple Sclerosis', European Philosophy of Medicine and Health Care 3 (3), special issue on CD–ROM.Google Scholar
  11. Dekkers, W.J.M.: 1998, 'Hermeneutics and Experiences of the Body. The Case of Low Back Pain', Theoretical Medicine 19, 277–293.CrossRefGoogle Scholar
  12. Dekkers, W.J.M.: 1999, 'The Lived Body as Aesthetic Object in Anthropological Medicine', Medicine, Health Care and Philosophy. A European Journal 2 (2), 117–128.CrossRefGoogle Scholar
  13. Donelly, S.: 1988, 'Human Selves, Chronic Illness, and the Ethics of Medicine', The Hastings Center Report (April/May) 18, 5–8.Google Scholar
  14. Drane, J.F.: 1985, 'The Many Faces of Competency', The Hasting Center Report (April) 15, 17–21.Google Scholar
  15. Duval, M.L.: 1984, 'Psychosocial Metaphors of Physical Distress Among MS Patients', Social Science and Medicine 19, 635–638.PubMedCrossRefGoogle Scholar
  16. Gillon, R. (ed.): 1994. Principles of Health Care Ethics. Chicester etc.: John Wiley.Google Scholar
  17. Greaves, D.: 'Conceptions of Impaired Capacity and Persons – the Example of Dementia' [unpublished paper].Google Scholar
  18. High, D.M.: 1989, 'Caring for Decisionally Incapacitated Elderly', Theoretical Medicine 10, 83–96.PubMedCrossRefGoogle Scholar
  19. Jennings, B., D. Callahan and A.L. Caplan</del>: 1988, 'Ethical Challenges of Chronic Illness', The Hastings Center Report (Feb./March) 18 (Special Supplement), 1–16.Google Scholar
  20. Manschot, H.: 1992, Levenskunst of lijfsbehoud? Een humanistische kritiek op het beginsel van autonomie in de gezondheidszorg. Utrecht: Universiteit voor Humanistiek.Google Scholar
  21. Manschot, H.: 1994, 'Kwetsbare autonomie. Over afhankelijkheid en onafhankelijkheid in de ethiek van de zorg', in: H. Manschot and M. Verkerk (eds.), Ethiek van de zorg. Een discussie. Amsterdam/Meppel: Boom, pp. 97–118.Google Scholar
  22. McCullough, L.B. and N.L. Wilson: 1995, 'Rethinking the Conceptual and Ethical Dimensions of Long–Term Care Decision Making', in: L.B. McCullough and N.L. Wilson (eds.), Long–Term Care Decisions. Ethical and Conceptual Dimensions. Baltimore/London: The Johns Hopkins University Press, pp. 1–12.Google Scholar
  23. Moody, H.R.: 1992, Ethics in an Aging Society. Baltimore: John Hopkins University Press.Google Scholar
  24. Robinson, I.: 1988, Multiple Sclerosis. London: Routledge, pp. 45–49, 77.Google Scholar
  25. Rolland, J.S.: 1983, 'A Conceptual Model of Chronic and Life Threatening Illness and Its Impact on Families', in: C.S. Chilman, E.W Nunnally and F.W. Cox (eds.), Chronic Illness and Disability. Newbury Park: Sage Publications.Google Scholar
  26. Seneca: 1979, Het Gelukkige Leven. Baarn: Ambo.Google Scholar
  27. Spaink, K.: 1992, Het strafbare lichaam. Amsterdam: De Balie.Google Scholar
  28. Spaink, K.: 1993, Vallende vrouw. Autobiografie van een lichaam. Amsterdam: Van Gennip.Google Scholar
  29. Toombs, S.K.: 1992a, The Meaning of Illness. The Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht etc.: Kluwer Academic Publishers.Google Scholar
  30. Toombs, S.K.: 1992, 'The Body in Multiple Sclerosis. A Patient's Perspective', in: Leder D. (ed.), The Body in Medical Thought and Practice. Dordrecht etc.: Kluwer Academic Publishers, pp. 127–137.Google Scholar
  31. Tronto, J.: 1993, Moral Boundaries. A Political Argument for an Ethic of Care. London: Routledge.Google Scholar
  32. Welie, J.V.M. and S.P.K. Welie: 2001, 'Patient Decision Making Competence. Outlines of a Conceptual Analysis', Medicine, Health Care and Philosophy. A European Journal 4 (2), 127–138.CrossRefGoogle Scholar
  33. Widdershoven, G.A.M.: 1995, Principe of praktijk? Een hermeneutische visie op gezondheid en zorg. Maastricht.Google Scholar

Copyright information

© Kluwer Academic Publishers 2001

Authors and Affiliations

  • Wim J. M. Dekkers
    • 1
  1. 1.Department of EthicsPhilosophy and History of MedicineNijmegenThe Netherlands

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