Abstract
I shall begin with a brief sketch of the East Asian principle of autonomy first proposed in Ruiping Fan’s “Self-determination vs. Family-determination: Two Incommensurable Principles of Autonomy.” (Fan argues elsewhere that the Western and Chinese models of medical decision making manifest two different perspectives of human life and human relations) The East Asian principle of autonomy supports family-sovereignty in bioethics as it regards the family and the patient together as an autonomous unit comprising the final authority in clinical decision making. Moreover, it assumes an objective conception of the good collectively understood by family members and it upholds harmonious dependence within the family.
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Notes
- 1.
Fan argues elsewhere that the Western and Chinese models of medical decision making manifest two different perspectives of human life and human relations. See Fan 2002.
- 2.
See Chap. 5.
- 3.
See Chap. 6.
- 4.
See Fan 1997. According to Beauchamp’s distinction, morality in the narrow sense is constituted by moral precepts that are vague, indeterminate, and yet universally binding whilst morality in the broad sense is constituted by moral precepts that are subject to further culturally and theoretically conditioned interpretations. Hence, no ethical precept in the broad sense of morality is absolute; only ethical precepts in the narrow sense of morality are universally binding. See Beauchamp 1996.
- 5.
Fan anticipates the objection that the East Asian principle of autonomy he proposes is not a principle of autonomy at all because it goes beyond the basic scope of the concept of autonomy as it is understood in the West. See Fan 1997, p. 321. I discuss the concept of autonomy in the last section of this chapter.
- 6.
Unfortunately bioethicists have not been able to resolve the question regarding what we are to respect in respecting autonomy. Different suggestions include: autonomous choice, autonomous execution of a choice, autonomous agency, and the will of an agent. The conceptual enquiry into the notion of autonomy goes beyond bioethics and becomes metaphysical.
- 7.
On Fan’s account, the other relevant persons in the clinical context would include family members, like the spouse, parents and adult children, in addition to the physician. Fan’s discussion makes no reference to people who are emotionally or psychologically close to one another, e.g., adopted families and other domestic and intimate relationships.
- 8.
Here I am using “the Western principle of autonomy” as a loose term, without specifying any particular formulation of the principle of autonomy in Western bioethics. The principle of autonomy takes a central place in Western bioethics as it is assigned the task of grounding informed consent. However, despite the primacy of the principle of autonomy, bioethicists have not been successful in formulating a universal principle of autonomy acceptable to all. In the final section of this chapter I discuss Beauchamp’s dissatisfaction with the unsuccessful attempts of bioethicists to establish a theory of autonomy that clearly “spells out its nature, its moral implications, its limits” (Beauchamp 2004, p. 214).
- 9.
In fact, even an incompetent patient in the West can exercise this final authority through arrangements like surrogate decision-making, living wills and advance directives. In general, the family is marginalized in clinical decision making in the West. As Mark J. Cherry notes, “The family is placed within a hermeneutic of suspicion, as failing to protect the best interests of its members” See Chap. 3 for an exegesis of the decline of the family under the individualistic character of the social-democratic egalitarian ideology that underlines the dominant approach to Western bioethics.
- 10.
See Stoljar 2011 for a recent example. Drawing on Charles Taylor’s social theory of agency and his communitarian arguments against the atomistic conception of the self, Stoljar argues that informed consent (in the sense of information plus noninterference) is not sufficient for patient autonomy partly because patients, as agents, “are situated in historical, social, class, race and gender contexts” (Stoljar 2011, p. 376). As such, this social situation has an impact on identity, self-conception, and the nature and development of important capacities like autonomy. In sum, autonomy is intrinsically social and relational because it is conditioned and limited by the social situation of human existence.In contrast, Jules Holroyd argues that the conditions for autonomous agency are not constitutively relational though the conditions for autonomous choice or autonomous action may be relational. See Holroyd 2009.
- 11.
Fan’s example is, “if a patient refuses treatment because he judges his life is no longer worth living, while the relevant others do not think so in terms of the objective conception of the good, the patient’s wish would not be followed, whether or not the patient is competent” (Fan 1997, p. 318).
- 12.
Rehbock depicts a bleak situation for the patient as a solo decision maker: “If one only has to read and sign a long paper with a good deal of information and is otherwise left alone with the final decision, one does not get the feeling that one’s autonomy is being respected” (Rehbock 2011, p. 526).
- 13.
- 14.
I thank Eirik Lang Harris for the example of relocation.
- 15.
The three core values are first articulated by Wang Guowei (1877–1927) in his study of the Zhou dynasty. Basically, zunzun means to respect those who have high status, qinqin means to maintain good relationships with one’s relatives, and xianxian means to appoint those who are virtuous and capable. The nine canonic principles for good governance are found in The Doctrines of the Mean.
- 16.
See Chap. 6, for his account of the nine canonic principles.
- 17.
In the Analects there are several sections on xiao, see 1.9, 1.11, 2.5–8, 4.18–21, 13.18, 17.21, 19.18
- 18.
A full explanation of this point is beyond the scope of this chapter.
- 19.
However, contrary to the “standard interpretation,” Joseph Chan argues that “classical Confucianism does contain important nonfamilial principles and values that can balance its familial ethics and constrain its tendency to cast everything in that light” (Chan 2004, p. 62).
A different approach can be found in Kim 2010. Instead of taking Confucian familism as “the critical obstacle to civil society”, Kim Sungmoon proposes “to reconstruct a civil society by creatively repossessing Confucian familism…and to present it as an alternative to liberal civil society, which is predicated on moral individualism and asserts its unique mode of civility (“socialiablity”) and citizenship (“strangership”)—tenets that are largely unpalatable to the Confucian moral sensibility” (Kim 2010, p. 477). On Kim’s view, a characteristically modern yet Confucian civil society can be founded on a moral individualism cultivated in Confucian familism.
- 20.
- 21.
Faden and Beauchamp state, “respect for autonomy is the most frequently mentioned moral principle in the literature on informed consent, where it is conceived as a principle rooted in the liberal Western tradition of the importance of individual freedom and choice, both for political life and for personal development” (Faden and Beauchamp 1986, p. 7).
- 22.
Things actually begin to change. For instance, the primacy of autonomy is challenged by James Taylor, who argues that “the ethical foundation of informed consent is really concern for human well-being” (Taylor 2005, p. 384).
- 23.
Choi suggests that Bruce Miller’s four senses of autonomy in bioethics (namely autonomy as free action, autonomy as authenticity, autonomy as effective deliberation, and autonomy as moral reflection) can be expanded to reflect the ideas of relational autonomy and family-oriented consent. His proposal is to incorporate consideration for other family members, as well as the community’s wellbeing, into autonomy as effective deliberation and to add the value of family and consideration of sound relationships between the self and others to autonomy as moral reflection. (See Chap. 5).
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Acknowledgments
I would like to thank the editor, Ruiping Fan, for his encouragement and patience. This chapter has benefited from valuable comments and constructive suggestions from Philip, J. Ivanhoe, Ho-Mun Chan, Sungmoon Kim, Eirik Lang Harris, Hektor King-tak Yan, Hsin-wen Lee, and Richard Kim during a monthly talk session in March 2013 at the Center for East Asian and Comparative Philosophy (CEACOP) at the City University of Hong Kong.
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Yung, L. (2015). The East Asian Family-Oriented Principle and the Concept of Autonomy. In: Fan, R. (eds) Family-Oriented Informed Consent. Philosophy and Medicine(), vol 121. Springer, Cham. https://doi.org/10.1007/978-3-319-12120-8_7
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