Academic journal article The Hastings Center Report

Displacing Decisions in Health Care

Academic journal article The Hastings Center Report

Displacing Decisions in Health Care

Article excerpt

At crucial moments of choice most of the business of choosing is already over.... The moral life is something that goes on continuously, not something that is switched off in between the occurrence of explicit moral choices. What happens in between such choices is indeed what is crucial.

--Iris Murdoch, The Sovereignty of Good

There is a remarkably sharp contrast between discussions of autonomy among ethical theorists and those among bioethicists working in the practical contexts of health care delivery, research, and legislation. Within ethical theory, recent neo-Kantians such as Barbara Herman, Thomas Hill, and Christine Korsgaard have developed increasingly subtle accounts of the metaphysics of autonomy and its connections to agency, morality, and personhood. These accounts are highly abstract, and their authors are not very concerned with figuring out how to empirically recognize, foster, and protect autonomy. And rightly so, for as bioethicists rarely remember, Kant himself believed that it was categorically impossible to empirically ascertain the existence or absence of autonomy. This was why he insisted that autonomy had to function as a regulative ideal governing action, not as an empirical criterion for measuring whether any given act is acceptable.

In the meantime, practical bioethicists demand a working notion of autonomy that is tied to empirical markers. They want to be able to make empirical judgments about whether or not a given agent is capable of acting autonomously, a particular decision is autonomous, a protocol adequately protects patient autonomy, and so forth. Again, rightly so, for their goal is to resolve concrete dilemmas that arise within the practice of medicine. Bioethicists should not be responsible for developing a comprehensive metaphysics of pure autonomy. Unfortunately, though, their current working notion is inadequate, and its inadequacy reflects and reinstates a history of considering only certain dimensions of health care as worthy of ethical attention.

There is in bioethics one clearly dominant account of autonomy, despite its having been subject to countless attacks and proposed enrichments. It finds its canonical expression in a single text, Beauchamp and Childress' repeatedly reprinted textbook Principles of Biomedical Ethics. (1) Recent works in bioethics call the paradigm established by Beauchamp and Childress "mainstream medical ethics," (2) the "standard model" in bioethics, (3) the "dominant picture," (4) and the "prevailing view." (5) In this picture, the "principle of autonomy" is one of the three basic principles of bioethics, along with principles of beneficence and justice. (6) Despite the officially equal status of these three principles, most bioethicists agree that among them, autonomy now receives a disproportionate share of attention. Furthermore, for most bioethicists, whose primary concern is with the ethical obligations of health professionals to patients, the principle of autonomy is simply the principle of respecting and promoting patient autonomy, as opposed to a more general Kantian principle demanding autonomous action on everyone's part. Paul Root Wolpe goes so far as to claim that "indisputably ... patient autonomy has become the most powerful principle in ethical decisionmaking in American medicine." (7)

According to the dominant account, we can roughly translate the principle of respecting patient autonomy into the principle of protecting and promoting patients' ability to make and act upon free, informed decisions resulting from capable and uninfluenced deliberation. So understood, autonomy turns on two broad conditions: (1) An autonomous agent is the center or location of her own decisions and actions; that is, they originate freely from her rather than being imposed upon her from the outside. (2) An autonomous agent more or less understands the facts about her situation and can engage in practical reason on the basis of this understanding. …

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