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Autonomy is a central principle in bioethics and research ethics. In this essay, a historical account of the moral and philosophical foundations for the principle of autonomy and its conceptualization in bioethical discourse is presented. An explanation on the application of autonomy in clinical practice and biomedical research by contextualizing it within a global bioethical framework is provided because the assumption of autonomy is that each person has the right and capacity to make her or his own decisions about medical procedures, treatment, and biomedical research. An examination of the challenges in the universality of the ethical concept of autonomy in bioethics is highlighted. The essay concludes with a summary of the major discussion points on autonomy.
The term “autonomy” comes from two Greek words, that is, aúto (auto), which means self, and nómoB (nomos), which means “rule” or “law.” Literally, autonomy means “self-rule.” A commonly shared understanding deﬁnes autonomy as, “self-governance” or “self-determination” (Mappes and DeGrazia 1996, p. 25). It is a concept found in moral, political, and bioethical philosophy. Within these contexts, autonomy is understood as the capacity of a rational individual to make an informed and uncoerced decision. This implies having intellectual capacity to differentiate good from evil/bad and right from wrong. It also means that one has the good will to pursue what is good and right as well as to avoid what is bad and wrong. The assumption of autonomy is that each human being has the right and capacity to make her or his own decisions about medical procedures, treatment, and participation in biomedical research. It empowers one to make his/her own decision or to participate in decision-making process. For an individual to make an autonomous decision, he/she requires adequate information that is understandable and noncoercive.
The concept of autonomy is actualized in asking for informed consent in both clinical care and biomedical research. For consent to be informed, it requires disclosure, understanding, free choice, and competence. In fact, competence is a precondition and a necessity for informed consent in both clinical practice and biomedical research. Competence could be the legal age of consent, and it requires rationality or the ability to comprehend or understand information and procedures. Informed consent is to be obtained in a context or environment that is voluntary and free from coercion, oppression, exploitation, and manipulation. Other ethical concepts that have evolved from the principle of autonomy are respect for conﬁdentiality and privacy. Respect for privacy and conﬁdentiality is linked to the principle of respect for persons and is, therefore, central to clinical practice and biomedical research. Barbara Secker (1999) goes as far to assert that it is arguably the paramount moral principle in bioethics, together with principles of beneﬁcence and justice. She argues that, despite the moral premium placed on autonomy, it is common to ﬁnd the term used rather intuitively. The concept is rarely given much analysis and thus frequently operates in bioethics as a vague, ambiguous, or elusive concept (Secker 1999). In what follows, a historical account of the moral and philosophical foundations of the principle of autonomy and its applications in both clinical/medical practice and biomedical research is provided. An explanation on the application of autonomy in clinical practice and biomedical research by contextualizing it within a global bioethical framework is given because the assumption of autonomy is that each person has the right and capacity to make her or his own decisions about medical procedures, treatment, and biomedical research. An examination of the challenges in the universality of the ethical concept of autonomy in bioethics is highlighted. The essay concludes with a summary of the major discussion points on autonomy.
A Historical Account On The Development Of The Principle Of Autonomy In Bioethics
The principle of autonomy is historically linked to the work of the German philosopher Immanuel Kant (1724–1804). Kant’s most inﬂuential arguments are contained in the books, The Groundwork of the Metaphysics of Morals. In fact, in his main theory of deontology, he formulated two guiding rules of conduct, which clearly deﬁne his concept of autonomy. It is in here that he espouses that moral requirements ought to be based on what he refers to as the categorical imperative. The two rules which comprise the categorical imperative are as follows: act only according to that maxim whereby you can at the same time will that it should become a universal law of humanity and act so that you treat humanity, whether in your own person or that of another, always as an end and never as a means only (Hoffman et al. 2001). In particular, the second formulation of the categorical imperative contends that a human being as a rational being should always be treated as an end in himself/ herself and not merely as a means to achieve another person’s end. This is because as rational agents, human beings are free agents that are capable of making their own decisions, setting their own goals, and guiding their behavior by reason. This conception of autonomy is rooted in the fact that human beings have an intrinsic worth or dignity that stems from their rationality or reason. Kant was convinced that a human being as a rational being is capable of making autonomous decisions based on good will and moral reasoning and not moralization. He explained that the good will is unique in that it is always good and maintains its moral value even when it fails to achieve its moral intentions. Kantian conception of autonomy became well known during the French Revolution and the Enlightenment in which individual rights received prominence in Europe. Initially, the ancient Greeks applied the notion of autonomy to city-states. But today, autonomy is often used as the basis for determining moral responsibility and accountability for one’s actions in both moral and political philosophy.
However, there are different conceptions of autonomy in the literature that are characterized by differences in interpretation and understanding. Kantian autonomy is manifested in a life in which duties are met, in which there is respect for others and their rights (O’Neill 2002a, p. 82). Kant’s view of autonomy is not a form of self-expression, but rather a matter of acting on certain sorts of principles and speciﬁcally on principles of obligation (O’Neill 2002a, p. 82). It is on this basis that Kant argues for respect for persons. According to Kant, respect for persons is required due to our inherent dignity, which in turn is due to our being rational creatures. Rational beings have the capacity to use reason in forming decisions and act not only in accordance with reason but also for the sake of reasons we believe are right. According to Kant, it is the capacity to choose right from wrong, and the responsibility that follows from possession of such a capacity, that accords persons the Kantian sense of dignity that deserves respect. So, what does it mean to treat someone with respect?
In everyday parlance, to treat another with respect means to regard him or her highly – to esteem, honor, and value in his or her uniqueness or distinctiveness and to make space for the person to be him or herself (Lysaught 2004, p. 665). What is more, the saying often entails a sense of deferring to the other, considering the other’s interests and feelings, attending to his or her needs, and looking out for the others’ well-being (Lysaught 2004, p. 665). Respect in ethical usage thus conceptualizes individuals as free and autonomous beings, by virtue of their inherent dignity. As Pellegrino (1994) observes, “Human beings are owed respect for their autonomy because they have an inherent dignity” (p. 49). This inbuilt worth requires persons to view each other as beings that are morally self-determining (http:// learn.yale.edu/hsp/module_1/2_respect.asp). To be a self-determining being requires that a person assume responsibility for his or her choices, actions, and decisions and act on the basis of informed reason and autonomously held principled commitments. To this end, others in turn must respect the moral agency and reasonable commitments of the person in this sense (Lysaught 2004, p. 665). This is what O’Neill (2002a) refers to as “principled autonomy” (p. 82). This is contrasted with what Stirrat and Gill (2005) refer to as “individualistic autonomy” (p. 127).
The origins of modern individualism can be traced to the Renaissance era that brought about the rationality of the Enlightenment and the struggle for personal and political freedom out of which Western democracies emerged (Stirrat and Gill 2005, p. 127). Western democracy and society strongly advocate the idea of liberalism, and this has been the dominant view in politics, philosophy, and the law. Liberalism is committed to an individualist ideal [sic]: the value and security of the individual; the primary importance of individual interests, freedoms, and rights; the need for privacy; and so on. This commitment to an individualist ideal advocates a general theory that positions the individual or gives priority of the individual over the society as a whole (Bird 1999, p. 6). As such, the dominant view of individualistic autonomy in much recent liberal bioethics is that it confers a right to act on one’s own judgment about matters affecting one’s life, without interference by others (Dunstan 1994). Now, when coupled, these two different interpretations or versions of autonomy – the principled and individualistic versions – embody the following ideals and moral obligations; ﬁrstly, respect for persons is a universal obligation that people have toward other people, because the individual is conceptualized as free and autonomous. Secondly, the individual has moral obligations to treat people with respect in recognition of the inherent dignity and moral worth that all persons have as human beings (Beach et al. 2007, pp. 692 and 694).
Application Of Autonomy In Clinical/ Medical Practice
In medical literature, the term autonomy is associated with “freedom” – that is, the right of individuals to act and make decisions without external constraints (Stiggelbout et al. 2004, p. 268). In other words, autonomy refers to the decision-making dimension of the patient role, and enhancing patient autonomy means helping patients make their own decisions (Stiggelbout et al. 2004, p. 268). Key to a patient’s ability to make his or her own decisions is information.
Information, in this context, enhances autonomy. Patients who actively seek information are generally seen as more autonomous because, in the liberal individualist interpretation, information is seen as a necessary condition for autonomous choice (Stiggelbout et al. 2004, p. 268).
Autonomy requires health professionals to obtain the informed consent of patients before any medical procedure is performed. Beauchamp and Childress in their seminal work, Principles of Biomedical Ethics, deﬁne autonomous patients as choosers who act intentionally, with understanding, and without controlling inﬂuences that determine their actions (Beauchamp and Childress 1994a). Given the above deﬁnition of an autonomous patient, autonomy is supposed to protect vulnerable patients from unwanted interference by health professionals by demanding respect for a patient’s integrity (Stiggelbout et al. 2004, p. 268). In order to respect the autonomy of patients, health professionals are required to give necessary information that is understandable and allow a competent patient to make a free choice regarding treatment or medical procedure. Before they get consent from the patients or their guardians, they have to explain the medical condition of the patient as well as the beneﬁts and risks of the treatment options. This assumes that patients are rational and reasonable agents capable of making voluntary decisions. In cases of minors and incompetent patients, they have to respect the wishes of the parents/guardians regarding treatment or medical procedure after disclosing the information. Autonomy also requires health professionals to maintain conﬁdentiality of medical information that patients provide to health professionals based on trust. It is not the prerogative of the health professional to make a decision for the medical beneﬁt of the patient without involving either the patient or his/her guardian since the health professional’s obligation to respect autonomy outweighs professional obligations of beneficence (Stiggelbout et al. 2004, p. 268).
There are various guidelines for professional autonomy in clinical practice, and these guidelines enforce professionalization as well as accountability and efﬁciency among health-care professionals (Klazinga 1994). They ensure that health-care professionals deliver optimal patient care by respecting the autonomy of their patients. However, one of the ethical dilemmas in medical practice is how to balance and manage conﬂicts of obligation between the principles of beneﬁcence and autonomy. Can one talk of benevolent deception or therapeutic privilege? Can a medical doctor or a health professional override a patient’s autonomy in the best medical interest of the patient? Indeed, there is a dispute about the primacy between principles of beneﬁcence and respect of autonomy on the one hand and benevolent paternalism on the other.
Balancing autonomy and beneﬁcence is one of the most difﬁcult ethical issues to navigate especially when patient’s autonomous decisions conﬂict with the physician’s beneﬁcent duty to look out for the patient’s best interests (Pantilat 2008). A couple of examples include when a patient who has had bypass surgery wants to continue to smoke or when a patient with pneumonia refuses antibiotics. In these situations, as long as the patient meets the criteria for making an autonomous choice, then the physician should respect the patient’s decision even while trying to convince the patient otherwise (Pantilat 2008). Other examples of a physician’s beneﬁcent duty to act in the best interest of the patient are more complex. It is suggested that a physician may exercise “therapeutic privilege,” that is, the physician can withhold information if they hold a reasonable belief that disclosure of a risk would prove damaging to the patient’s health. To withhold information in these circumstances, the practitioner would need to make a judgment, on reasonable grounds, that the patient’s physical or mental health might be seriously harmed by the information. The types of factors governing therapeutic privilege include the patient’s personality, temperament, or attitude, their level of understanding, the nature of the treatment, and the likelihood of adverse effects resulting from the treatment (NSW Health Department 2005). For example, if a patient is suicidal and matters concerning their health may lead them to attempt to take their lives, a physician may justiﬁably consider invoking therapeutic privileges to the treatment, care, and management of the patient.
Application Of Autonomy In Biomedical Research
In biomedical research, the concept of autonomy is embodied in the principle of respect for persons or autonomy, which is one of the basic principles of research ethics. The Belmont Report was the ﬁrst document that highlighted the notion of respect for persons in research ethics although its application was documented in the Nuremberg Code. As Lysaught notes, Belmont began by explicitly stating that the notion of respect for persons incorporates two ethical convictions. The ﬁrst acknowledges autonomy, noting that individuals should be treated as autonomous agents. The second ethical conviction maintains that persons with diminished autonomy deserve extra protection (Lysaught 2004). This principle empowers one to make independent decisions or to participate in decision-making process (Walter and Klein 2003). Autonomy requires biomedical researchers to provide necessary information that is understandable to a competent potential research participant or their guardian/parent/ legally authorized representative and free of coercion and manipulation before potential individual research participants decide to participate in their research projects. It is actualized in asking for informed consent from a potential research participant before his/her participation in biomedical research. The theory and practice of informed consent in biomedical research received prominence during the Nuremberg trials of the Nazi doctors after World War II (The Nuremberg Code 1949). The atrocities committed by the Nazi doctors in the experiments on prisoners of war captured by the German soldiers during World War II brought it to the attention of the world that respect for autonomy was an important doctrine to uphold. Hence, the Nuremberg Code became the ﬁrst landmark research ethics code that required biomedical researchers to obtain voluntary consent of the human subject (The Nuremberg Code 1949). Subsequent research ethics guidelines codiﬁed the requirement for obtaining informed consent from potential research participants and put safeguards for the protection of research participants’ autonomy and safety.
The principle of autonomy also obliges biomedical researchers to tell the truth and to respect conﬁdentiality and privacy of their research participants. Both privacy and conﬁdentiality deal with ownership, control, and access to personal information, personal property, and the body. In all research ethics guidelines, informed consent is considered as an ongoing process during research participation. This means biomedical researchers are required to continue obtaining consent from their research participants throughout the research process. This is part of ensuring that participant’s autonomy is continually being respected.
Tensions And Limits To The Application Of Autonomy In Bioethics
Recent examples of outbreaks in communicable diseases such as Ebola, H1N1, and MDR-TB highlight tensions between collective interests and individual autonomy. In particular, the methods used to justify involuntary conﬁnement or quarantine by governments to manage public health threats reveal that the concept of autonomy is not absolute but can be limited by the law in accordance to Siracusa Principles. Of course, justifying involuntary conﬁnement of speciﬁc patients is always controversial because it represents a signiﬁcant deprivation of an individual’s freedom of movement and runs the risk of resulting in limiting other civil liberties, such as privacy, nondiscrimination, and freedom from arbitrary detention (Boggio et al. 2013). The Siracusa Principles are employed to examine the legality of the proposed action as well as the evidence-based necessity given the perceived public health threat. If consideration is given to the welfare of healthy individuals and society at large, then involuntary conﬁnement can be legitimate and permissible when public health interests are carefully balanced against individual patient interests. The recent case of Ebola in West Africa illustrates that quarantine methods are justiﬁed to protect both human rights to health and health as a public good (Boggio et al. 2013). In this manner, autonomy does not imply absolute independence but a responsible interdependence that means one’s autonomy stops where someone’s autonomy begins.
Another challenge to autonomy emerges when a physician may have to disclose sensitive medical information to a third party, also understood as the duty to warn. Physicians, as part of their professional obligations to their patients, are not permitted to disclose any medical information without the full knowledge of their patients, the purpose of which is to allow the patient to exercise his or her autonomy. Furthermore, because the physician-patient relationship is an ethical relationship based on mutual trust, this relationship operates in the context of treating each other as equals. If trust is an intrinsic value in medical ethics, it follows that the physician will protect the conﬁdential nature of the information in respect to the autonomy of the patient. However, there are occasions when the trustworthiness of the physician to the patient may be sacriﬁced because the patient’s actions may put others at risk, for example. The duty to protect third parties has been acknowledged as justiﬁcation for breach of patient autonomy and conﬁdentiality under special circumstances. The Tarasoff v. Regents of the University of California case illustrates this tension between autonomy and beneﬁcence. In this particular case that occurred in the United States of America, the Supreme Court in California ruled that breach of conﬁdentiality and, therefore, patient autonomy were justiﬁed if there is an imminent risk of serious and preventable harm to an identiﬁed other (Leung 2002, p. 58).
Differences between moral and religious beliefs between the physician and the patient, for example, can also create tensions. Abortion is an example that highlights how differences in moral and religious beliefs can be a barrier to providing women with access to safe abortion services. There are some health-care providers who will refuse to participate in providing abortion services to women on moral and religious grounds (Skuter 2012, p. 1). This is known as conscientious objection. In these circumstances, patients may need to understand that “The physician as a human being has the same claim to respect for his or her capacity to make personal choices, to follow his or her conscience about what is good in medicine and what is morally acceptable as a person” (Pellegrino 1994, p. 51). Respecting a physician for his personal ethics in clinical practice is a difﬁcult thing because society generally understands the role of the physician as a beneﬁcent one. However, it is important that patients understand that his or her “moral right of autonomy must be balanced with respect for the physician’s autonomy” (Pellegrino 1994, p. 51). This is because “the physician-patient relationship is one of mutual obligation – like any truly ethical relationship” (Pellegrino 1994, p. 51). As such, balancing the patient’s moral right of autonomy with respect to the physician’s moral right to autonomy requires that there be a mutually reinforcing relationship that promotes integrity and beneﬁcence in medical ethics.
Challenges To The Universality Of Autonomy In Bioethics
The universal validity of autonomy in Western bioethics has been challenged at several points by non-Western cultures still proud of their communal relations and spiritualistic ethos (Blackhall et al. 1995). Non-Western literature on autonomy suggests the idea that autonomy in the Western sense does not readily apply to other cultural or ethnic groups. It is not the concept of autonomy that is totally alien to non-Western cultures; only that while the West emphasizes individual autonomy, non-Western cultures place greater emphasis on cultural, communal, or family autonomy (Kushe and Singer 2013a). For many cultures, however, the perception of self and the individual is deﬁned by relationships with others (Blackhall et al. 1995). In non-Western cultures and traditions, family duties and obligations take precedence (Bowman et al. 2004). For instance, greater value and meaning are given to the interdependence of family and community which transcends self-determination or individual autonomy. This tradition emphasizes the value of a holistic view of a person that afﬁrms the importance of the community, society, and the family. This is so because in most traditional cultures, the community always comes ﬁrst before the individual. In fact, the individual is born out of and into the community. When a patient’s perception of self is intimately connected to and deﬁned by their relationships with others, they may consult family members or relatives before giving their consent to medical procedures or to participate in biomedical research. This is what has been characterized as “family-centered” decision-making style (Blackhall et al. 1995). Of course, this does not mean that their decisions are not autonomous. “Rather, it means broadening our understanding for respect for persons so that it includes respect for cultural values they bring with them to the decision-making process” (Blackhall et al. 1995, p. 825). It is important to note that this family-centered model of decision-making also enhances autonomy in the sense that the ﬁnal decisions are made by the individuals themselves although they get advice from their fellow family members, relatives, or community members. Such decisions may be informed as it were by inputs from family members, relatives, or community members.
This essay has presented a historical and philosophical account of the moral foundations for the principle of autonomy and its conceptualization in bioethical discourse. It is very important to realize how the ideas of people like Kant have impacted on bioethical deliberations in Western societies, as they have been important in deﬁning personhood from the Western point of view. A discussion on the application of autonomy to clinical practice and touched on the tensions that can arise when autonomy is prized was presented. Here the focus was on presenting the principle of autonomy as it is applied in biomedical research. It is clear that the atrocities committed in the past have necessitated the protection of human participants in research. Finally, an examination of the notion of autonomy in the context of the discourse in global bioethics was presented. It is increasingly apparent that the notion of autonomy, just like any utopian idea, relies on several assumptions, including the wish that each and every person has the rational capacity to make decisions and is free from constraints. These assumptions can be challenged, and it has been demonstrated how the universal validity of autonomy is challenged in terms of its application to the medical decision-making process.
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