In its ethical cookbook, medicine needs more than autonomy

No one wants to go back to the bad old days of medicine. Not only were treatment options limited, crude and often harmful, but doctors often failed to treat their patients as persons, and instead as objects of scientific inquiry and experimentation.

The same is true of the more recent past: think of the cruel medical experiments of Nazi doctors, or, closer to home, to the ghastly Tuskegee Syphilis Trial. ‘First do no harm’ has often been, and continues to be, flouted. Medicine is an ineluctably moral pursuit, for it involves interactions with persons. It needs to be thought of and through as such.

Add to this the technological advances of modern medicine, and the ethical problems that arise from them, and it becomes clear why a branch of practical ethics has been developing in tandem with medicine: medical ethics. It is certainly an important subject. Everyone knows that dilemmas and complex situations arise frequently in medical practice, and need to be answered rationally.

How, then, are we to do medical ethics? This question has many answers because ethics is not monolithic (Deontology, Utilitarianism, Natural Law Theory, Virtue Ethics etc.), so neither can medical ethics be. Moreover—to state the obvious—nor every doctor has the time to study for a PhD is moral philosophy.

Hence, to simplify practical ethics for the healthcare professional, Beauchamp and Childress offered in 1979 Principles of Biomedical Ethics. It is a thorough attempt to systematise medical ethics for the sake of the busy practitioner. Now famously, it identifies four principles with which to think through the moral aspects of medicine: Beneficence, Non-Maleficence, Justice and Respect of Autonomy.

These four principles form the basis of principlism. Putting this to work at the bedside means thinking through a moral dilemma or situation by considering each of the four principles in turn, balancing their relative importance to one another, and specifying rules from this process. This system of ethics is taught very widely in medical schools today. It is highly regarded and often cited. To date, seven editions of Principles of Biomedical Ethics have been printed.

Despite the apparent reasonableness of principlism, it has not escaped the notice of many, that autonomy tends dominate the other principles in practice. And, certainly, in much of the medical ethics literature, considerations of autonomy seem to take priority over all other aspects of ethics. Plenty of people have offered their criticisms of principlism and autonomy ethics, but what I did in a recent paper in an academic journal, Medicine, Health Care and Philosophy, was consider the origins of this principle of autonomy. Where did it come from? And why does it dominate today?

In antiquity, autonomy had nothing to do with individuals. It was all about the ability of city-states to rule themselves, and it was not until the Enlightenment that it took on very different meanings from this.

The Enlightenment was a tumultuous time of overthrowal of traditional power and authority. No longer could God be appealed to as an authority, nor would the Church’s teaching hold sway universally. The old morality had been dissolved, but a vacuum was left in its place. It fell to the philosophers to fill it by reconstructing morality without appeal to revelation or tradition, and do so in a way still capable of binding society together. This ‘Enlightenment Project’ was undertaken by two important philosophers: Jean-Jacques Rousseau and Immanuel Kant.

Rousseau (1712-1788) knew that society could only cohere if held together by something greater than individuals’ desires. He thought that contract can achieve this: if each member of society agrees to give up some rights in return for some liberties or privileges, then everyone can get along. The way to act rightly then, grossly speaking, becomes respecting the terms of contract. So, we must consider others and their autonomous consent to contract with us. Significantly, this entails that the fact of a contract is more important that its content; Rousseau’s autonomy of contract leads to the suggestion that anything goes if it is permitted.

Kant (1724-1804) did not much care for Rousseau’s autonomy of contract. For Kant, moral autonomy is the way to think about ethics. For an individual to act autonomously he must deduce the moral law from the first principles of reason, and act in a way which he would obey a universal rule. To subsequently fail to obey reason in this way is to fail to be autonomous. One must impose the law of autonomy on oneself to act morally, be ruled by reason—which is starkly different from Rousseau’s lowest common denominator morality.

Of course, both are problematic. Autonomy of contract can lead us to think that morality is a mere social convention, and therefore not a serious subject of rational inquiry. Moral autonomy, despite attempting to ground itself in reason alone, runs the risk of becoming highly subjective when disagreements arise about what universal rules should be. Indeed, later thinkers soon abandoned Kant’s radical rationality in favour of radical individualism. The collective aspect of Rousseau’s theory was forgotten too, and thus the scene was set for political liberalism and individual autonomy.

If there is no consensus about the ends or purposes of human action, then these cannot be the object of government policy. We agree to disagree on matters, and accept that each decided for himself what is the good life. That is political liberalism in a nutshell, and it is only plausible because of the Enlightenment. The state becomes agnostic as to what is good and evil and takes a step back in the legislating for or against matters considered moral, as moral consensus changes over time. Non-interference becomes the keystone of morality, holding up the precarious bridge of contract.

Autonomy thus takes on the meaning of being one’s own person, doing what one wishes, what is most authentically ‘self’. It is self-rule without Kant’s reason, or Rousseau’s collectivism. This individual autonomy does not mean thinking about reason, or thinking about others, but thinking about oneself.

And, crucially, this means that duties derived from autonomy fall not on the one wishing to make a principled decision, but on everyone else who must respect it. Autonomy is no longer a privilege (Rousseau) or a duty (Kant), but an entitlement.

I do not mean to suggest that only bad has come from this. Medical practice has greatly improved over time, and, on balance, there is much more awareness of and respect for patients’ human dignity. But, as I see it, this evolution of autonomy has two problems.

Firstly, leaning heavily on autonomy has the effect of excluding from human society those who do not possess it. It is one of the greatest fallacies of the Enlightenment that membership to society is based on choice and the ability to make a contract. There are many in our society who cannot do this, either because they are immature, ill, or disabled. Limiting ethical and political discussion to matters of autonomy excludes such people, and therefore threatens their interests.

Secondly, our current social and political context is such natural fit for an ethic of autonomy that it makes it difficult for us to think outside this box. Philosophy and history are deeply interwoven subjects, meaning that our current context cannot but shape our understanding of ethics, and, if we are not careful, blind us to alternative possibilities. How difficult it has become to talk about ends and not just means in ethics, and how rare it is to read a defence of a substantive view of human goods and flourishing.

If autonomy is given priority in ethical inquiry, it spells the end of the same. If ethics is about inquiring as to what is good and evil, and determining how to choose the first and avoid the second, amidst the complications life, then we need more categories to work with than individual autonomy. It takes more for us, as moral agents and persons, to be the best we can be, and achieve the good for ourselves and others, than merely doing whatever seems best in our eyes.

Ethics needs a clear conception of those basic human goods which should be protected and pursued. Otherwise, it is a largely redundant field of inquiry.

Now, I do not recommend that doctors should blithely overrule their patient’s wishes. Indeed, if autonomy means anything in medicine, it means the patient’s right to say no. As the theologian Paul Ramsey put said, “no man is good enough to cure another without his consent”.

The point is that, if we are to think about ethics better, we need to understand where autonomy comes from, why it enjoys such popularity today, and what alternatives are available to it. I hope this brief article has covered the first two points, albeit very superficially. The third point deserves many books-length treatments.

What is pertinent, however, is that autonomy is not the panacea to the excesses and crimes of medical practitioners. Indeed, for those who do not have a voice, who cannot make contracts with the rest of us, such as the unborn or the terminally frail, autonomy might be the very thing which undoes the slow process by which doctors are coming to see their patients as persons.

Toni C. Saad writes from Cardiff University School of Medicine, in Cardiff, Wales, UK

Republished with permission.

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