Academic journal article The Hastings Center Report

Reassessing Autonomy in Long-Term Care

Academic journal article The Hastings Center Report

Reassessing Autonomy in Long-Term Care

Article excerpt

Reassessing Autonomy in Long-Term Care

Long-term care is an increasingly important subject for bioethical reffection and analysis, yet when viewed through the spectacles of autonomy, the pivotal concept of much bioethical theory, the realities of long-term care sem paradoxical to say the least. [1] The most striking feature of long-term care is that adult individuals suffering from diseases and illnesses of being old experience a compromised vigor and ability to function that requires regular care ranging from help in activities of daily living such as housework, food preparation, and hygiene to highly skilled nursing and medical care. Elders requiring long-term care generally exhibit functional disabilities that frequently bring with them vulnerabilities as well. They exhibit various kinds of dependencies and not the independence so prized by the traditional view of autonomy that stresses values of independence and rational free choice.

Traditional treatments of autonomy simply abstract from actual examples of finite human autonomy and contexts of choice and focus instead on idealizations of autonomous action and choice. As Onora O'Neill has pointed out:

The limitations of actual human autonomy aren't taken as constraints on working out the determinate implications with respect to autonomy in actual contexts, but often as aberrations from ideally autonomous choosing. The rhetoric of the liberal tradition shows this clearly. Although it is accepted that we are discussing the autonomy of "finite rational beings," finitude of all sorts is constantly forgotten in favor of loftier and more abstract perspectives. [2]

In short, a concrete concept of autonomy is needed if it is to play a significant analytical and practical role in long-term care.

The abstract liberal concept of autonomy has its proper place in the legal/political sphere, where protection of individuals from tyranny and oppression by powerful others is rightly defended, but not in the moral life, where a fuller conception is required, once that acknowledges the essential social nature of human development and recognizes dependence as a nonaccidental feature of the human condition. Such a concept would systematically attend to the history and development of persons and take the experiences of daily living into account; it would view individuals concretely and see choice as a problem of positively providing options that are meaningful for concrete individuals rather than as an issue of removing obstacles to choice or impediments to action. Such a refurbished concept would offer important advantages for capturing the ethical complexities of long-term care.

Autonomy as Independence

As conceived in the western liberal tradition, autonomy focuses on independence of action, speech, and thought. The ideals implicit in this concept include independence and self-determination, the ability to make rational and free decisions, and the ability to identify accurately one's desires and to assess what constitutes one's own best interest. So construed, autonomy supports a broad set of rights that provide the normative basis from which tyranny, oppression, and even the benevolent use of power over vulnerable individuals have been opposed. These features are certainly defensible and need to be preserved, but we must critically acknowledge that the underlying idea of independence that has come to dominate our understanding of autonomy is an idealization entangled in the historical roots of this tradition in seventeenth-century political and legal debates. Thus, we should not expect a fully adequate picture of what autonomy means in those heterogeneous circumstances that comprise the moral life from this important, but limited context. Unfortunately, this limited orientation has enjoyed a central place not only in academic ethical discourse, but public discourse as well.

According to this view, to be a person is by definition to be capable of free and rational choice; such abilities provide the ethical foundation for the expression of uniquely individual beliefs, desires, preferences, and values. …

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