Abstract
Respect for Autonomy (RFA) has been a mainstay of medical ethics since its enshrinement as one of the four principles of biomedical ethics by Beauchamp and Childress’ in the late 1970s. This paper traces the development of this modern concept from Antiquity to the present day, paying attention to its Enlightenment origins in Kant and Rousseau. The rapid C20th developments of bioethics and RFA are then considered in the context of the post-war period and American socio-political thought. The validity and utility of the RFA are discussed in light of this philosophical-historical account. It is concluded that it is not necessary to embrace an ethic of autonomy in order to guard patients from coercion or paternalism, and that, on the contrary, the dominance of autonomy threatens to undermine those very things which have helped doctors come to view and respect their patients as persons.
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Notes
Principlism is now the mainstream system of ethics taught in medical undergraduate syllabuses, and is used as a reference point by many in the field. Its monopoly means that it often evades scrutiny. It is applied before it is explicated or justified. This paper will assist lay teachers of principlism to better understand its origins, and, as a result, its strengths and weaknesses.
A large section of Ancient Greek medicine was not Hippocratic it should be noted.
These notions stand in contrast to common modern-day understandings of autonomy, though we will later argue that the contractualist understanding of autonomy is a questionable concession to personal autonomy.
This is often known as negative freedom.
In contrast to Hobbesian egoistic contractualism.
What is more, Kant believes that this sort of autonomy, or at least possessing the capacity for it, is grounds for the innate dignity of human nature (Scruton 2001, 436). In other words, persons should not be treated merely as means to an end, but also as ends in themselves, because they are capable of exercising autonomy. This connection between autonomy and dignity re-emerges in our era, and proves to be significant in the discussion of contemporary issues such as the treatment of minimally conscious patients and infants.
Kant wrote much on this subject in both Critique of Pure Reason and Critique of Practical Reason. We can only scratch the surface of the subject here.
“There is a difference of form between reasoning leading to action and reasoning for the truth of a conclusion” (Intention, 33).
Though it is also possible to draw on revelation in this regard.
Practical reason moves from ‘is’ to ‘ought’ but this is consistent with itself. For, as Anscombe points out, to exposit a syllogism of practical reason to state all the premises and thereby clarify the connection between ‘is’ and ‘ought’, makes it absurd because it then bears no resemblance to the mental process which led to it (Intention, 42).
It is a bitter irony that the NC should be drafted in Germany as a response to such evil: the recently toppled regime possessed the world’s most advanced laws concerning safety in human experimentation. It became painfully obvious that these laws were not enforced (Faden et al. 1986, 152–157).
The key word here is “rhetorical”, for we have shown that even Belmont’s understanding of respect for persons leans very heavily on assumptions of autonomy, and therefore differs less from RFA than it is similar. The criticisms laid out in this section could be levelled at Belmont too, but RFA spells them out more explicitly.
Indeed, it would seem that a version of preference utilitarianism is the most natural ethical development once autonomy is accepted not merely as a right to refuse treatment but as a right to choose treatment even if it against the patients’ best interests. For an example of this see Minerva (2017).
Some may wish to refute these arguments, and maintain that ethics does not require a conception of what is good to function. Many such cases can and have been made. Our aim is not to rebuff these all here, but merely to signal that ethics without a concrete conception of human goods looks very different from an ethics of autonomy. Also, the acceptance of such views of ethics are synchronous with the developments in though this essay has described; it is highly likely there is a connection between the two, be it right or wrong in principal.
Again, for clarity, this particular line of reasoning is offered mainly as way of explanation, not evaluation of theories of autonomy.
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Acknowledgements
The author would like to thank Dr Trevor Stammers for overseeing this work as part of the MA programme in bioethics at St Mary’s University, Twickenham.
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Saad, T.C. The history of autonomy in medicine from antiquity to principlism. Med Health Care and Philos 21, 125–137 (2018). https://doi.org/10.1007/s11019-017-9781-2
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DOI: https://doi.org/10.1007/s11019-017-9781-2