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This entry analyzes the concept of autonomy and the content and scope of the principle of respect for autonomy in contemporary global bioethics. The ﬁrst section presents historical and intellectual roots of the idea of autonomy. The second section provides basic conceptual clariﬁcations: distinction between autonomy as capacity and autonomy as the right to self-determination, and evolution from autonomy of persons to autonomy of decisions and actions. The third and central section of the entry focuses on the meaning and role of the principle of respect for autonomy in the context of modern medical clinical practice and research. First, conditions for autonomous choices and actions are discussed. Second, the notion of respect as an action-guiding attitude is explained. Subsequently, the normative consequences of the principle of respect for autonomy for the patient-physician and the subject researcher relationships are presented. Third, the question of limits of the principle of respect for autonomy is addressed in the context of common types of conﬂicts between the principle and other moral principles and values. Finally, critiques of the emphasis on the value of autonomy in contemporary moral and political philosophical in general and in bioethics in particular are mentioned.
The concept of autonomy is a relatively new arrival in ethics, but it has become a central idea in contemporary moral and political philosophy. Autonomy – as both the capacity and right to self-determination – is a foundational idea of bioethics. It is routinely appealed to in bioethical literature and in various ethical guidelines for clinical practice and medical research involving humans. The principle of respect for autonomy provides a basis and context for a large portion of ethical standards for medical professionals and investigators. It is standardly held that their obligation to obtain informed consent is a main instrument of protection of patients’ and research subjects’ autonomy. The principle of respect for autonomy also justiﬁes the professional duties of truthfulness and honesty, avoidance of coercion, and privacy protection. To a lesser extent it is discussed in contexts related to the professional and personal autonomy of clinicians and researchers.
The centrality of the principle of respect for autonomy in contemporary bioethics is accompanied by difﬁculties that are associated with promotion of other important values and principles, such as individual well-being, public health, professional integrity, or access to healthcare. Proper balancing between autonomy and those other values remains a constant challenge to scholars, medical professionals, and researchers. Autonomy is also an object of criticisms, which stress the importance of community life, personal relations, and respect for cultural diversity.
Historical Development Of The Concept Of Autonomy
There are two main currents which led to development of the idea of autonomy as it is known today. The ﬁrst line of its development has an ancient Greek origin (ca. ﬁfth c. BC) when it was understood as a political ideal of a city-state’s independence from foreign domination or rule of a tyrant’s will. The concept was occasionally mentioned in ancient Roman literature and neglected in the Middle Ages. It began to have some significance in German legal literature in the sixteenth century when it referred to freedom of thought and religion. In the beginning of the seventeenth century, autonomy was a subject of theoretical work in the ﬁeld of jurisprudence and law where it signiﬁed independence of the lawgiver or individual liberty. In the eighteenth century, autonomy was sometimes understood as a ruler’s privilege to make laws, other times as a prerogative of corporate bodies to enact rules that are binding for their members. By that time, a distinction between public and private autonomy was established, the former referring to the law-making power of the general will and the latter to an individual’s sovereignty over their property (Pohlmann 1971).
The second current in the history of the idea of autonomy concerns the relation between religion and morality, in particular the question of the justiﬁcation of moral principles. Such questions were brought mainly by the Reformation. Around the seventeenth century, the idea of self-governance emerged in the writings of natural law theorists, notably Hugo Grotius, later to be more and more present in the works of, among others, Jean-Jacques Rousseau and Christian Wolff who provided inspiration to Immanuel Kant. Kant was the ﬁrst to use the concept of autonomy as the required foundation of morality (Schneewind 1998). For Kant autonomy is the capacity of rational beings to legislate moral norms that relies on a formal principle (the Categorical Imperative) which makes these norms self-justiﬁed. Morality does not require subordination to laws given by any authority “external” to the agent or by God but involves a rational being’s independent recognition of moral standards, which provides such beings with motivation to follow those standards (Kant 1785/1999; Kant 1788/1999).
Although John Stuart Mill did not use the word “autonomy,” he wrote about individual liberty as the precondition of both individual and social well-being. He famously held that everyone should be allowed to act according to their own judgment. He argued that “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufﬁcient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right” (Mill 1859/1989, p. 13). Today’s idea of autonomy, found both in philosophy and in bioethics, derives mainly from Mill’s philosophy and signiﬁes individual freedom of arriving at moral beliefs and action upon them. The Kantian philosophical roots are more prominent in discussions of respect for autonomy.
Autonomy: Conceptual Clarifications
Autonomy As Capacity And Autonomy As Right
Autonomy is a complex idea. It comprises the capacity of a person to choose according to her beliefs and preferences and a right to make her own decisions. As capacity, autonomy refers to a set of cognitive skills, emotional responses, and attitudes which allow a person to reﬂect on and make decisions about her own or others’ actions, which affect that person, and to act on the ground of those decisions. It requires, among others, awareness of one’s situation and available options of action and ability to calculate means to ends, to plan one’s own actions, and to implement one’s decisions. Autonomy as capacity is closely related to decisional competency and can have various degrees, depending on an individual’s potential or state of mind and the social and natural environment in which decisions are made. A person may therefore be more or less autonomous, i.e., make more or less autonomous decisions that express her beliefs, preferences , and value commitments. Autonomy can change in time and may be modiﬁed by such factors as illness, disability, emotional state, or actions of other individuals. Although autonomy as capacity is predicated on individual persons, it is a function of various factors, some of which are personal (such as skills, patterns of emotional response, or illness) and others are external (such as availability of resources or inﬂuences by others).
As a right, autonomy is a right to self-determination or to the liberty to make decisions which concern the decision-maker and express her beliefs, desires, and value commitments. It is afforded to beings who, in virtue of their cognitive, rational, and emotional potential, are able to make their own decisions and are aware of that ability. As a right, autonomy does not have degrees. It is either accorded to an individual or not on the ground of that individual’s possession of certain morally signiﬁcant characteristics (which are often seen as those which deﬁne a person, e.g., capacity for rational thinking and self-awareness) or, simply, being a member of the human species. It is possible, however, that a person who formally has the right to make decisions does not have the capacity to make them due to factors that can be temporary (such as illness or severe stress) or permanent (such as mental disability or irreversible loss of consciousness).
Autonomy Of A Person And Autonomy Of A Decision And Action
Autonomy, understood as comprising both capacity and right, is predicated on a person as a whole rather than on her individual actions. A philosophical conception which expresses this general idea of autonomous person is the view which had been offered independently by Dworkin (1988), who developed his account for bioethics, and Frankfurt (1971), who offered a more general approach. On this theory, a person has two orders of desires. Desires of ﬁrst order (understood as wants and aversions) are desires to do or refrain from certain actions and have or avoid certain things. Second-order (or higher order) desires are desires about desires of a lower order. An autonomous person reﬂects on her ﬁrst-order (or lower-order) desires to approve or disapprove of them (i.e., to form a higher-order desire or align a lower-order desire with the desire of a higher order) and in this way to promote her goals. For example, a patient may be afraid of a surgical intervention, yet upon reﬂection she may come to the conclusion that the fear should be resisted and decide to undergo surgery that she believes will promote her goal of being able to live a physically active life.
This conception of autonomous person expresses the idea of authenticity in thought, decision, and action. Autonomous persons are those who are capable of reﬂecting on their beliefs and desires and actively shape their personalities and acting accordingly (or authentically), i.e., they choose the beliefs and attitudes that are to guide their decisions and actions.
Autonomy of person is an attractive and commonly shared moral and political ideal in today’s developed societies. Its usefulness in clinical or research contexts is however limited, as it is hard to operationalize it for the purpose of respect for autonomy, whose central form is seeking a patient’s or potential research subject’s informed consent. A pragmatic approach to this problem has been offered by Faden and Beauchamp (1986), who concentrate on the idea of autonomy of decision and action rather than that of person. According to their argument, what is important is autonomy of action, not person, ﬁrstly, because autonomous persons do not always act or decide autonomously; secondly, because clinical and research contexts require clarity whether a given decision or action is autonomous or not; and thirdly, because determination of autonomy must conform with legal standards concerning informed consent. This approach is widely accepted in bioethical literature, medical practice, and research.
Personal Autonomy And Professional Autonomy
In contemporary bioethics autonomy is most often discussed with reference to individuals’ capacity and right to act on the basis of their own personal beliefs, desires, and value commitments (personal autonomy). However, the concept of autonomy can also apply to medical professionals’ right to treat the patient without interference with their best professionally based judgments (professional autonomy). Professional autonomy is closely related to professional identity and to professional integrity. It presupposes and guarantees high-quality, evidence-based, and patient-centered medical care. In the discussion of autonomy presented below, emphasis will be placed on patients and research subjects’ personal autonomy, as it is the main area of current bioethical interest. The topic of professional autonomy will only be touched upon in connection with conﬂicts between physicians’ freedom to exercise their professional judgment in the care of their patients and demands of just allocation of limited healthcare resources or other public health concerns.
Respect For Autonomy In Bioethics: Ethical Dimension
The principle of respect for autonomy is one of the core moral principles in bioethics. In a most general sense, it obliges people, in particular healthcare providers and medical researchers, to respect autonomous decisions and actions of others, i.e., patients and research subjects. However, to determine what the principle requires in detail and what its scope is, it is necessary to clarify, ﬁrst, what sort of individual choices and actions qualify as autonomous, and so deserving respect, and second, what the term “respect” stands for and how it translates into ethical requirements in the world of medicine.
Conditions for Autonomous Decisions and Actions
The following presentation of autonomy of action or decision follows the view of a patient’s or research subject’s autonomous decision, offered by Faden and Beauchamp (1986).
An action or decision of a patient or potential medical research participant is held to be autonomous if it satisﬁes simultaneously the following three conditions. First, the decision or action must be intentional or wanted, i.e., the decision-maker must be aware that she is making a decision (as opposed to an unreﬂective or casual yes or no) and she must will the particular course of action she chooses. It can be willed for itself (e.g., a person agrees for a treatment in order to restore her health) or as a means to other ends (e.g., a patient consents for a knee surgery because she wants to take part in a next year’s marathon) or as unavoidable or tolerated “side effect” of the actions she chooses for one of the other two reasons (e.g., a person accepts a disﬁguring scar following lifesaving surgery). Thus, for an autonomous decision both the action itself and its consequences must be willed by the decision-maker. Since this conception of autonomy is designed for the context of informed consent, intentionality is assumed to have no degrees. Healthcare professionals or researchers need a clear declaration of a patient’s or potential research subject’s will. This non-gradual assumption is made for pragmatic purposes, despite an intuitive understanding of intentionality, according to which something can be intended to a greater or lesser degree.
Second, for a decision or action to be autonomous, the patient or research subject must understand the planned action. The basis for understanding is adequate information provided by the healthcare professional or researcher. It should include, among others, the following key categories of information: the diagnosis, prognosis, the nature of the proposed interventions, and their expected beneﬁts, risks, and possible side effects. The information must be presented in a comprehensible form and manner, as it must allow the patient or research participant to have a possibly clear and realistic idea of what the healthcare professional or researcher proposes. It should allow the recipient to achieve both intellectual and emotional understandings of the proposed treatment or study.
The third condition for an autonomous decision or action is absence of controlling inﬂuences on the process of decision-making. Such inﬂuences comprise all activities and circumstances which have been intentionally arranged so as to increase the likelihood that the decision-making process will result in a particular decision, irrespective of the decision-maker’s legitimate beliefs, desires, and value commitments. Susceptibility to control is variable and depends of an individual’s personality and character. What is controlling for one person may not be such for someone else. Controlling inﬂuences will not include the circumstances that are unavoidable (e.g., the emotional stress caused by bad diagnosis) or have not been intentionally arranged but their removal would be too difﬁcult, burdensome, or impossible. Among controlling inﬂuences will usually be manipulation, lying, nondisclosure of information, coercion, threats, or suggestions of urgency in non-urgent situations.
The three conditions for autonomous action or decision allow patients or research subjects to make choices that express their beliefs, desires, and value commitments. As could be seen from the description of autonomous action above, for the ideal of autonomy to be realized, it is not enough to make autonomous decisions or act autonomously. It is also necessary that those who interact with autonomous persons relate to their autonomy in an appropriate way, i.e., that they respect it.
Respect For Autonomy: Its Nature And Dimensions
Respect is an action-guiding attitude taken toward an object which is believed to be of special value. Unlike promotion of goals, respect does not require merely bringing about consequences but is such a response to that value which delimits the repertoire of actions available to the respectful person in relation to the object of respect. Similarly, respect for autonomy does not consist in promotion of any goals in particular (i.e., states of affairs desired by an autonomous agent), but in recognition of the value of autonomy.
Respect for autonomy is often indistinguishable from respect for persons. It is autonomous persons whose ideals, beliefs, and value commitments are respected. Respect for autonomy is therefore respect for the capacity and right of persons to determine their own fortunes. It gives rise to two sorts of obligations – negative and positive (Beauchamp and Childress 2012). Most basically, respect for autonomy requires giving persons independence in their decisions and actions to the extent to which they do not harm others or do not violate others’ rights. Thus, it translates into negative obligation not to subject autonomous persons’ decisions and actions to controlling inﬂuences. More demandingly, and in keeping with Kant’s ethical thought, respect for autonomy requires that persons always be treated as ends in themselves and never as mere means, that is, they must be treated as individuals who posit ends or choose things and actions as worthy of pursuit. It means that autonomous persons may be treated as means to other ends but only under the condition that their consent to such treatment had been secured ﬁrst. For this reason respect for autonomy materializes predominantly in making sure that actions that are to affect persons are accepted by them. It also gives rise to positive obligations to foster autonomous decision-making of persons and to obtain their prior authorization.
Respect For Autonomy Of Patients And Research Subjects
The principle of respect for autonomy has important normative consequences for medical practice and research. First, it requires that legitimate choices of patients or research subjects (i.e., those which do not interfere with the rights of others and do not produce harms to them) must not be ignored and that they must be conceded to. The fundamental framework for respect for autonomy of patients or research subjects is provided by informed consent or refusal, i.e., acts of will by which they accept interventions which are consistent with or reject those which are contrary to their beliefs, desires, and value commitments. Medical professionals are obliged to obtain consent of a person who is capable of giving it for each and every treatment or research, and they are obliged to respect the patient’s or research subject’s objection or withdrawal of previously given consent. The principle of respect for autonomy demands from the professionals not only not to interfere with the persons’ decisions, through subjecting them to coercion or other controlling inﬂuences, but also to positively promote patients’ or research subjects’ ability to make autonomous choices in agreement with the latter’s own beliefs, desires, and value commitments. Clinicians and researchers should facilitate patients’ or research subjects’ decisions in a way which makes the decisions genuine or expressive of their actual preferences . Accordingly, it would constitute disrespect for a competent patient’s autonomy to ignore his request to stop a treatment he is undergoing, even if such withdrawal were to lead to his death. It would also be disrespectful of a competent patient’s autonomy if a physician did not attempt to concede to a religiously motivated wish of the patient to be examined by a physician of the same sex as the patient’s in a healthcare facility which employs such a physician.
Second, respect for autonomy requires provision of truthful and adequate information and avoidance of all forms of deception, manipulation, or bias. If patients or research subjects are to determine their futures according to their beliefs, desires, and value commitments, they must have access to true information about the purpose and nature of the proposed medical interventions and their consequences, risks, and burdens. Information is vital for the realization of patients’ or research participants’ potential of aligning their lives with their beliefs, desires, and commitments. The information provided to the patient can be more or less elaborate and detailed, depending on the nature and consequences of the proposed intervention, gravity of decision, and its potential consequences. More complex or serious interventions (e.g., extensive cardiac surgery) will usually require more exhaustive and speciﬁc information, whereas simpler and less consequential interventions (e.g., treatment of a common cold) will command less detailed information. The information also needs to be adapted to the beliefs and attitudes of the patient or potential research participant, and it should respond to their legitimate expectations. Individuals’ plans, religious beliefs, and moral and personal commitments may determine the types of information which will be needed for a particular person to make a decision. For example, for a Jehovah’s Witness, the likelihood of the need to use blood products or their composition may be more important from the point of view of making an autonomous decision than for a Catholic or nonbeliever. The scope and depth of the information provided to patients must also agree with their wishes. Accordingly, patients are allowed to decide how extensive or detailed this information should be. In particular, they are free to refuse to receive that information or some parts of it, and they must be provided with those elements of information which pertain to the intervention under consideration and that are of interest to them.
Third, respect for autonomy requires respect for privacy, which implies the professional duty of conﬁdentiality. Since autonomous persons need to shape their fortunes, respect for their autonomy demands that they have control over the information pertaining to them and that they be free from negative effects of others’ access to that information. Medical professionals have access to private and intimate aspects of information pertaining to patients. In order to respect a patient’s autonomy, medical professionals must protect conﬁdential information and access to it by unauthorized individuals. With the exemption of situations in which welfare of other individuals, public health safety, or other legitimate public interests are involved, medical professionals are not allowed to provide conﬁdential information to anyone who is not necessary for the provision of healthcare or carrying out research without prior explicit consent of the patient or research subject.
Limits Of The Principle Of Respect For Autonomy
The principles of respect for autonomy provide a foundation for many traditionally recognized ethical obligations of clinicians and researchers. It does not mean, however, that autonomous choices or decisions of patients or research subjects should be protected without limitations. Despite the factual centrality of autonomy in contemporary bioethics, there are other important moral values with which autonomy needs to be balanced. For example, in the well-known framework for medical ethics developed by Beauchamp and Childress (2012), often referred to as principlism, respect for autonomy is one of basic general moral principles together with nonmaleﬁcence, beneﬁcence, and justice. In theory, none of the principles has absolute priority; therefore, in situations of conﬂict between them, balancing of their relative weights and strength is needed. Autonomy is also considered one of the core principles in European bioethics and biolaw. However, it must be always placed and interpreted in the context of care for others that presupposes an ethic of solidarity, responsibility, and justice, as well as in relation to and – in case of conﬂict – against three other basic values, namely, dignity, integrity, and vulnerability (Rendtorff 2002).
So, the principle of respect for autonomy does not exhaust the moral landscape of modern medicine nor does it outweigh all other moral principles and values at all times. Since it is impossible here to set the limits of the principle in abstracto or to present a comprehensive procedure for justifying its infringement in particular circumstances, in what follows four common types of conﬂicts between the principle of respect for patient’s autonomy and other moral considerations relevant for clinical practice will be discussed.
Firstly, a patient’s autonomous decisions or actions may violate rights or cause harm to others and as such come into conﬂict with the medical professional’s obligation of nonmaleﬁcence. Consider, for example, prospective parents’ desire to have a child afﬂicted with a disease or disability (e.g., deafness), that can be satisﬁed by means of preimplantation or prenatal diagnosis, followed by gamete or embryo selection, or, perhaps, selective abortion. Although procreative autonomy is an important part of personal autonomy, many bioethicists believe that such procreative choices, even if autonomous, should not be respected, as they harm prospective offspring or infringe upon their future autonomy (or, as some commentators say, their right to an open future). The future persons should be protected against having important life choices determined by others before they have the ability to make such choices for themselves. Similar arguments are launched by those who object to a parents’ right to decide whether their children will undergo genetic testing for a carrier status or for a mutation associated with a late-onset genetic disease for which preventive or therapeutic measures are not available. Critics argue that respect for autonomy (and privacy) of the children – as future moral agents – should override the parents’ wishes. Decisions about undergoing such tests should be deferred until the minor reaches maturity and becomes able to make them himor herself. Parental autonomy should not be protected at the expense of welfare and rights of others.
Secondly, a patient’s wishes and expectations may come into conﬂict with the physician’s convictions about the scope of his professional obligations or – to put it in broader terms – about the proper goals and uses of medicine. The view that medical practice, in contrast to proﬁt-oriented business and customer-focused enterprise, is a profession dedicated to saving lives, healing, and promoting health is often upheld. According to this view, physicians (and other healthcare providers) are obliged to use their professional knowledge and skills only to attain these goals. They should aim to satisfy the patient’s healthrelated needs, not any and all kinds of human desires. And they should act according to professional standards, both of a technical and an ethical nature, which are subordinated to the proper aims of medicine, not accordingly to the wishes of those they are taking care of.
Although this view of the nature of medical practice is shared by many healthcare givers, it is not uniformly supported by philosophers of medicine and medical ethicists. In fact, there is strong disagreement in the literature on whether such goals of medicine exist at all and, if so, what their nature and content is and how the concept of health (essential for distinguishing therapeutic uses of medicine from non-therapeutic ones) should be interpreted. These theoretical debates are exacerbated by a growing commercialization and consumerism in modern healthcare. Patients increasingly behave like clients who order and pay for medical services that are non-therapeutically indicated but fulﬁll their individual desires for improved appearance, enhanced performance, or just simply convenience. Today’s medicine offers, and many patients expect, invasive plastic surgeries, elective caesarean sections, drugs improving physical or mental powers beyond the range of normal functioning at given age (e.g., hormone replacement therapy), or – in a few countries – physician-assisted suicide. It is not clear whether they all serve the traditional goals of medicine of preservation and restoration of health.
Despite such debates, there is no doubt that patients (or their proxies) have no right to effectively demand from physicians that physicians furnish them with services that are evidently beyond the scope of the latter’s professional qualiﬁcations, evidently nonbeneﬁcial and contrary to evidence-based medicine (prescription of antibiotics against viral infections, administration of untested drugs), physiologically futile (intensive care for the brain-dead), or evidently harmful or illegal (heart procurement from a living donor on his autonomous request). Such services are against the core tenets of medical professionalism, and, therefore, healthcare providers are often seen as entitled to refuse performing them, against patients’ wishes.
Thirdly, since a clinical encounter is a relation between two moral agents – patient and healthcare provider – an autonomous decision of the former may come into conﬂict with personal autonomy of the latter. Legal abortion is a typical example here. A woman’s decision to terminate a pregnancy may come into conﬂict with the physician’s personal beliefs about moral or religious impermissibility of the procedure. It may be argued that autonomy of each of the parties deserves equal respect. If the patient has the right to refuse being subjected to medical procedures she considers to be morally unacceptable, the physician should also have a right to refuse to perform services he or she seems to be immoral. However, the existence and the scope of the physician’s right to abstain from offering certain types of medical care with which he or she does not personally agree must be viewed in the broader context of individual rights and professional duties. On the one hand, physicians, like all humans, have a right to freedom of thought, conscience, and religion, which are widely recognized human rights. Thus, it might be argued that their moral integrity should not be infringed upon by dictates of laws or patients’ requests. On the other hand, physicians voluntarily underwent professional education and consciously decided to enter the medical profession, being aware of the professional role related moral and legal obligations. Moreover, due to their unique knowledge and skills, they are endowed by societies with monopolistic rights and duties to perform certain interventions on human bodies. Therefore, their right to refuse a contested service cannot be unlimited, as it may result in an infringement of the patient’s right to healthcare as well as the patient’s right to self-determination. Many jurisdictions have implemented the so-called conscientious objection or conscience clauses, which are legal provisions setting conditions under which physicians (or other healthcare providers) may refuse to perform a medical procedure that is against their personal beliefs. Although the scope of the clause varies, there is a growing consensus that medical professionals should have a right to abstain from performing procedures they oppose for moral or religious reasons, provided that patients are informed of any conscientious objection in a timely manner, referred to another healthcare provider, and so that they are not deprived of appropriate medical care, in particular in cases of emergency.
Fourthly, both patients’ autonomy and physicians’ professional autonomy may come into conﬂict with demands of just allocation of inescapably limited healthcare resources or with public health concerns. In developed societies physicians’ obligations extend beyond the medical needs of their patients. Medical professions are a crucial component of healthcare systems, i.e., complex networks of people, institutions, and resources aimed at delivering medical services for the population. Although all modern societies have been striving to develop effective models of healthcare funding, none of them can afford to provide all individuals in need with the best appropriate medical care. The priority setting and rationing is unavoidable. Thus, no patient can expect any and all medical interventions he or she wants or considers beneﬁcial for his or her health, and so no healthcare provider has full professional autonomy in prescribing and delivering all the medical services he or she conceives to
be appropriate for his or her patient. The necessity of making decisions regarding allocation of scarce resources force medical professionals to take into account the consequences of their clinical decisions for other present and future patients.
Being a vital component of healthcare systems, medical professionals are not only obliged to provide medical services to individual patients, but they also play an important role in health promotion, disease prevention, and life prolongation among the population as a whole. These public health-related duties may come into conﬂict with their obligation to respect individuals’ autonomy and their rights to liberty, privacy, and conﬁdentiality. For example, when a person’s health status poses a serious threat to public health, he might be subjected to mandatory testing, quarantine, or even treatment, if there are no alternative and less intrusive methods to protect others and the society at large against the potential harm.
Critiques Of Autonomy
Autonomy is a basic moral concept of modern times. Many ethicists tacitly or explicitly see it as a dominant moral consideration in medical ethics. There are however at least three groups of thinkers: communitarians, ethicists of care, and scholars representing non-Western moral traditions, who criticize the high place autonomy occupies in moral and political philosophy in general and bioethics in particular.
Communitarians argue that the autonomy orientation of contemporary bioethics stems from a liberal individualistic vision of human nature and society. Liberals, communitarians claim, understand persons as separate, self-sufﬁcient “atoms,” whose identities, purposes, and values are self-chosen and prior to any social or communal attachments. To use Michael Sandel’s expression, persons are viewed as “unencumbered selves.” “For the unencumbered self, what matters above all, what is most essential to our personhood, are not the ends we choose, but our capacity to choose them” (Sandel 1984, p. 86). This concept of autonomy, understood in a procedural sense as an ability to make free choices, is attractive for liberals. But its view on moral agency is, according to communitarians, ﬂawed. Humans are social beings, and to a signiﬁcant extent they are constituted by the communities they are members of. Persons are always embedded in communities that are built around and held together by certain visions of a good life, values, practices, traditions, and institutions. Too great an emphasis on individual autonomy, rights, and private good may endanger the identity, stability, and existence of communities. Therefore, communitarians believe that the welfare of the community or society as a whole, rather than individual free choices, should be a starting point for ethical analysis and that the latter should be judged not only from purely procedural perspective but also subject to substantive moral reﬂection. “The claim that so called private choices should be exempt from moral analysis is the death of ethics. Private choices can be right and wrong, good and bad.. .,” and if they are evidently wrong or bad, when judged from a communitarian perspective, it is justiﬁed to constrain them (Callahan 2003, pp. 505–506).
The ethicists of care share with communitarians the relational vision of the human being, but they focus primarily on personal and caring relationships as the starting point of ethics. The ethics of care has been developed mainly by feminist scholars as a critique of a “masculine” tradition in moral philosophy built upon principles of autonomy, rationality, independence, impartial application of universal moral rules and obligations, and protection of individuals’ rights. The feminist critics argue that such a vision of moral agency is incomplete, as it does not take into account a “different voice”– the moral experience (usually of women) that afﬁrms the importance of emotions, mutual dependence, and caring relationships for the shape and content of human moral life. Care, trust, and context-sensitive responsiveness to needs of the vulnerable or weak – these all are morally important attitudes that should not be neglected. The care ethic perspective, according to its adherents, provides important moral insight into the patient-physician/ nurse relationship. In a healthcare context, care ethicists say, sensitivity and attentiveness to particular needs of those who are suffering and ill are likely to be more morally desirable than impersonal respect for their autonomy and rights (Kuhse 1997).
Criticisms of the centrality of autonomy in medical ethics have been also launched by non-Western scholars, from a broader, multicultural perspective. They point out that not all cultural traditions cherish autonomy, independence, and individuality. These are values characteristic for Western liberal and pluralistic societies, especially for the American culture, but alien to many traditional collectivistic societies in which familial or communal values and needs precede and override individual interests. In such societies, a person deﬁnes, actualizes, and realizes herself primarily through fulﬁlling socially ascribed roles and the role-related responsibilities and duties which serve the common good. An individual is always a “person-in-relations,” For example, “in a Confucian context, the family, more than the individual, is often considered as one basic unit in the two aspects of doctor-patient relationships. Medical ethical decision making tends to respect the opinions and decisions made or agreed to by the family as a whole. Given the concept of relational personhood, the emphasis on family values, the large role and responsibility family usually take in caring for sick persons, and the interconnectedness and interdependence between family members, families must be taken seriously” (Fu-Chang Tsai 2001, p. 48). In patriarchal communities, on the other hand, which traditionally deny women an independent social standing, healthcare-related decisions are undertaken by their male patrons – fathers, husbands, or brothers. Autonomy of women is not recognized in such cultures neither by their male nor female members.
The main concept of autonomy operative in bioethics is the Faden and Beauchamp’s idea of autonomy of decision and action. It stresses the need for adequate information and freedom from undue controlling inﬂuences affecting the patient’s or research subject’s decision, and as such it has an emancipatory power for patients and research subjects. This concept of autonomy is also a building block of the principle of respect for autonomy, which is now and will remain a central normative idea for clinical medicine and research involving humans. The principle of respect for autonomy has rich normative ramiﬁcations. It provides foundation for the medical-professional duties of obtaining consent, truthfulness, honesty, avoidance of coercion, and conﬁdentiality, some of which have been recognized throughout the history of medicine. The principle of respect for autonomy must also be balanced against other key principles, in particular: nonmaleﬁcence, beneﬁcence, and justice. Although respect for autonomy is and will continue to be a constant in bioethical thinking and guidelines for clinicians and researchers, it is possible that the role of autonomy in bioethical thought, although still central, will be more nuanced than it had been in the foundational days of bioethics.
There remain important theoretical and practical questions. One group of issues relates to the exact balancing of the different ethical requirements with the principle of respect for autonomy. Another important issue, particularly poignant in diverse democratic societies, is that of conﬂicts between autonomies of different persons, in particular of the physician and the patient. Both scholars and practitioners will have to address questions of relation between respect for autonomy and communal life and the role of the latter in shaping identities and decisions of individuals in healthcare and medical research. Another important issue is that of intercultural context of the principle of respect for autonomy and its inﬂuence on bioethical standards.
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