Abstract
In healthcare ethics there is a discussion regarding whether autonomy of personal preferences, what sometimes is referred to as authenticity, is necessary for autonomous decision-making. It has been argued that patients’ decisions that lack sufficient authenticity could be deemed as non-autonomous and be justifiably overruled by healthcare staff. The present paper discusses this issue in relation certain psychiatric disorders. It takes its starting point in recent qualitative studies of the experiences and thoughts of patients’ with anorexia nervosa where issues related to authenticity seem particularly relevant. The paper examines different interpretations of authenticity relevant for autonomy and concludes that the concept, as it has been elaborated in recent debate, is highly problematic to use as a criterion for autonomous decision-making in healthcare.
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Notes
We use preference, desire, and value synonymously in this text when referring to a person’s pro-attitudes towards something, e.g. a state of affairs.
This general characterisation of autonomy says nothing in itself about how autonomy matters morally. As noted previously, in biomedical ethics, autonomy has primarily been considered as giving rise to negative rights or side-restrictions for how healthcare personnel or biomedical researchers are allowed to treat patients or research subjects.
Authenticity has many meanings, not all of them exclusively focusing on the autonomy of desires, as in this text (see e.g. the seminal discussion in Taylor 1992). These other meanings will be disregarded in this article.
According to some influential contributors to the autonomy debate, authenticity is the most fundamental or philosophically most interesting component of autonomy, see e.g. Christman 1988. On the other hand, some debaters argue that authenticity in this sense is not a prerequisite of autonomy; see, e.g., Oshana 2007.
An adaptive preference in Elster’s sense is, roughly speaking, a preference formed in response to the set of options feasible for the agent (Elster 1982). However, we will not go into details about his account in this context. .
Although these concepts are sometimes differently defined (see, for instance, Brülde and Tengland 2003, pp 53-54), such differences in meaning are irrelevant to the present discussion and will be ignored.
This argument for autonomy, or authenticity, being incompatible with compulsory beliefs and desires cannot be found in the literature—there the incompatibility is taken for granted. Rather, we have tried to formulate what we think may be the underlying line of reasoning.
In full, the criterion reads: “Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight”, see American Psychiatric Association 2000 p 545, where the last disjunct may be interpreted as a disturbance in attitude rather than belief.
However, some hold that this is only necessary; e.g. Bruckner, who claims that reflection also should include the content of the desire and not just its cause (Bruckner 2011, p 457).
Of course, this can be questioned. Colburn 2011, argues that adaptive preferences in Elster’s sense cannot be authentic (using a notion of autonomy very similar to ours, Colburn 2011, p 61), since they are the result of covert influence, i.e. their formation is necessarily unconscious (Colburn 2011, p 68). We believe that Bruckner successfully argues that covert influence is compatible with them being authentic (in our sense); see Bruckner 2011.
References
American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed./text revision. Washington, DC: American Psychiatric Association.
Beauchamp, T.L., and J.F. Childress. 2009. Principles of biomedical ethics, 6th ed. Oxford: Oxford University Press.
Buchanan, A.E., and D.W. Brock. 1990. Deciding for others: The ethics of surrogate decision making. Cambridge: Cambridge University Press.
Bruckner, D.W. 2009. In defence of adaptive preferences. Philosophical Studies 142: 307–324.
Bruckner, D.W. 2011. Colburn on covert influences. Utilitas 23: 451–457.
Brülde, B., and A. Tengland. 2003 Hälsa och sjukdom—en begreppslig utredning (Health and malady—a conceptual inquiry). Lund: Studentlitteratur.
Christman, J. 1988. Constructing the inner citadel: Recent work on the concept of autonomy. Ethics 99: 109–124.
Christman, J. 2009. The politics of persons: Individual autonomy and socio-historical selves. Cambridge: Cambridge University Press.
Colburn, D. 2011. Autonomy and adaptive preferences. Utilitas 23: 52–71.
DeGrazia, D. 2005. Human identity and bioethics. Cambridge: Cambridge University Press.
Dworkin, G. 1988. The theory and practice of autonomy. Cambridge: Cambridge University Press.
Elks, M.L. 1994. On the genesis of anorexia nervosa—a feminist perspective. Medical Hypotheses 42: 180–182.
Elliot, C. 1997. Caring about risks: Are severely depressed patients competent to consent to research? Archives of General Psychiatry 54: 113–116.
Elster, J. 1983. Sour Grapes: Studies in the Subversion of Rationality. Cambridge: Cambridge University Press.
Fitzsimmons-Craft, E.E. 2011. Social psychological theories of disordered eating in college women: Review and integration. Clinical Psychology Review 31: 1224–1237.
Frankfurt, H.G. 1971. Freedom of the will and the concept of a person. Journal of Philosophy 68: 5–20.
Grisso, T., and P.S. Appelbaum. 1998. Assessing competence to consent to treatment. Oxford: Oxford University Press.
Gillon, R. 2003. Four scenarios. Journal of Medical Ethics 29: 267–268.
Hope, T., J. Tan, A. Stewart, and R. Fitzpatrick. 2011. Anorexia nervosa and the language of authenticity. Hastings Center Report 41: 19–29.
Juth, N. 2005. Genetic information: Values and rights. Gothenburg: Acta Universitatis Gothoburgensis. 2012. Saarbrücken: Lambert Academic Publishing (reprint of Juth 2005 with minor revisions).
Miller, B.L. 1981. Autonomy and the refusal of lifesaving treatment. Hastings Center Report 11: 22–28.
Nordenfelt, L. 2007. Rationality and compulsion: Applying action theory to psychiatry. Oxford: Oxford University Press.
Oshana, M.L.A. 2007. Autonomy and the question of authenticity. Social Theory and Practice 33: 2007.
Parfit, D. 2011. On what matters, vol. one. Oxford: Oxford University Press.
The British Medical Association. 2008. Mental capacity toolkit, card 3. Retrieved at: http://bma.org.uk/practical-support-at-work/ethics/mental-capacity-tool-kit. 28 Dec 2012.
Tan, J. 2003. The anorexia talking? Lancet 362: 1246.
Tan, J., A. Stewart, R. Fitzpatrick, and T. Hope. 2006. Competence to make treatment decisions in anorexia nervosa: Thinking processes and values. Philosophy, Psychiatry and Psychology 13: 267–282.
Tännsjö, T. 1999. Coercive care: The ethics of choice in health and medicine. London and New York: Routledge.
Taylor, C. 1992. The ethics of authenticity. Harvard: Harvard University Press.
World Medical Association. 2005. Declaration of Lisbon on the rights of the patient. Retrieved at http://www.wma.net/en/30publications/10policies/l4/. 28 Dec 2012.
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Sjöstrand, M., Juth, N. Authenticity and psychiatric disorder: does autonomy of personal preferences matter?. Med Health Care and Philos 17, 115–122 (2014). https://doi.org/10.1007/s11019-013-9509-x
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DOI: https://doi.org/10.1007/s11019-013-9509-x