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Identity, Personhood and Power Identity, personhood and power: a critical analysis of the principle of respect for autonomy and the idea of informed consent, and their implementation in an androgynous and multicultural society Dr Theresa Marié Rossouw Dissertation presented for the degree of Doctor of Philosophy at Stellenbosch University Promotor: Prof AA van Niekerk March 2012 Stellenbosch University http://scholar.sun.ac.za DECLARATION By submitting this dissertation electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the authorship owner thereof (unless to the extent explicitly otherwise stated) and that I have not previously in its entirety or in part submitted it for obtaining any qualification. Signature: Date: March 2012 Copyright © 2012 Stellenbosch University All rights reserved 2 Stellenbosch University http://scholar.sun.ac.za Abstract Autonomy and informed consent are two interrelated concepts given much prominence in contemporary biomedical discourse. The word autonomy, from the Greek autos (self) and nomos (rule), originally referred to the self-governance of independent Hellenic states, but was extended to individuals during the time of the Enlightenment, most notably through the work of Immanuel Kant and John Stuart Mill. In healthcare, the autonomy model is grounded in the idea of the dignity of persons and the claim people have on each other to privacy, self-direction, the establishment of their own values and life plans based on information and reasoning, and the freedom to act on the results of their contemplation. Autonomy thus finds expression in the ethical and legal requirement of informed consent. Feminists and multiculturalists have however argued that since autonomy rests on the Enlightenment ideals of rationality, objectivity and independence, unconstrained by emotional and spiritual qualities, it serves to isolate the individual and thus fails to rectify the dehumanisation and depersonalisation of modern scientific medical practice. It only serves to exacerbate the problematic power-differential between doctor and patient. Medicine is a unique profession since it operates in a space where religion, morality, metaphysics, science and culture come together. It is a privileged space because health care providers assume responsibility for the care of their patients outside the usual moral space defined by equality and autonomy. Patients necessarily relinquish some of their autonomy and power to experts and autonomy thus cannot account for the moral calling that epitomizes and defines medicine. Recognition of the dependence of patients need not be viewed negatively as a lack of autonomy or incompetence, but could rather reinforce the understanding of our shared human vulnerability and that we are all ultimately patients. There is however no need to abandon the concept of autonomy altogether. A world without autonomy is unconceivable. When we recognise how the concept functions in the modern world as a social construct, we can harness its positive properties to create a new form of identity. We can utilise the possibility of self-stylization embedded in autonomy to fashion ourselves into responsible moral agents that are responsive not only to ourselves, but also to others, whether in our own species or in that of another. Responsible agency depends on mature deliberators that are mindful of the necessary diversity of the moral life and the complex nature of the 3 Stellenbosch University http://scholar.sun.ac.za moral subject. I thus argue that the development of modern individualism should not be rejected altogether, since we cannot return to some pre-modern sense of community, or transcend it altogether in some postmodern deconstruction of the self. We also do not need to search for a different word to supplant the concept of autonomy in moral life. What we rather need is a different attitude of being in the world; an attitude that strives for holism, not only of the self, but also of the moral community. We can only be whole if we acknowledge and embrace our interdependence as social and moral beings, as Homo moralis. 4 Stellenbosch University http://scholar.sun.ac.za Opsomming Outonomie en ingeligte toestemming is twee nou verwante konsepte wat beide prominensie in moderne bioetiese diskoers verwerf het. Die woord outonomie, van die Grieks autos (self) en nomos (reël), het oorspronklik verwys na die selfbestuur van onafhanklike Griekse state, maar is in die tyd van die Verligting uitgebrei om ook na individue te verwys, grotendeels deur die werk van Immanuel Kant en John Stuart Mill. In medisyne is die outonomie model gegrond op die idee van die waardigheid van die persoon en die beroep wat mense op mekaar het tot privaatheid, selfbepaling, die daarstelling van hulle eie waardesisteem en lewensplan, gebasseer op inligting en redenasie, en die vryheid om op die uitkoms van sulke redenasie te reageer. Outonomie word dus vergestalt in die etiese en wetlike bepaling van ingeligte toestemming. Feministe en multikulturele denkers beweer egter dat, siende outonomie gebasseer is op die Verligting ideale van rasionaliteit, objektiwiteit en onafhanklikheid, sonder die nodige begrensing deur emosionele en spirituele kwaliteite, dit die individu noodsaaklik isoleer en dus nie die dehumanisering en depersonalisering van moderne wetenskaplike mediese praktyk teenwerk nie. As sulks, vererger dit dus die problematiese magsverskil tussen die dokter en pasiënt. Die beroep van medisyne is ‘n unieke professie aangesien dit werksaam is in die sfeer waar geloof, moraliteit, metafisika, wetenskap en kultuur bymekaar kom. Dit is ‘n bevoorregde spasie aangesien gesondheidswerkers verantwoordelikheid vir die sorg van hulle pasiënte aanvaar buite die gewone morele spasie wat deur gelykheid en outonomie gedefinieer word. Pasiënte moet noodgedwonge van hulle outonomie en mag aan deskundiges afstaan en outonomie kan dus nie genoegsaam die morele roeping wat medisyne saamvat en definieer, vasvang nie. Bewustheid van die afhanklikheid van pasiënte hoef egter nie in ‘n negatiewe lig, as gebrek aan outonomie of onbevoegtheid, beskou te word nie, maar moet eerder die begrip van ons gedeelde menslike kwesbaarheid en die wete dat ons almal uiteindelik pasiënte is, versterk. Dit is verder nie nodig om die konsep van outonomie heeltemal te verwerp nie. ‘n Wêreld sonder outonomie is ondenkbaar. Wanneer ons bewus word van hoe die konsep in die moderne wêreld as ‘n sosiale konstruk funksioneer, kan ons die positiewe aspekte daarvan inspan om ‘n nuwe identiteit te bewerkstellig. Ons kan die moontlikheid van self-stilering, ingesluit in outonomie, gebruik om onsself in verantwoordelike morele 5 Stellenbosch University http://scholar.sun.ac.za agente te omskep sodat ons nie slegs teenoor onsself verantwoordelik is nie, maar ook teenoor ander, hetsy in ons eie spesie of in ‘n ander. Verantwoordelike agentskap is afhanklik van volwasse denkers wat gedagtig is aan die noodsaaklike diversiteit van die morele lewe en die komplekse aard van die morele subjek. Ek voer dus aan dat die ontwikkeling van moderne individualisme nie volstrek verwerp moet word nie, siende dat ons nie na ‘n tipe premoderne vorm van gemeenskap kan terugkeer, of dit oortref deur ‘n postmoderne dekonstruksie van die self nie. Ons het verder ook nie ‘n nuwe woord nodig om die konsep van outonomie in die morele lewe mee te vervang nie. Ons het eerder ‘n ander instelling van ons menswees in die wêreld nodig; ‘n instelling wat streef na volkomendheid, nie net van onsself nie, maar ook van die morele gemeenskap. Ons kan slegs volkome wees wanneer ons ons interafhanklikheid as sosiale en morele entiteite, as Homo moralis, erken en aangryp. 6 Stellenbosch University http://scholar.sun.ac.za Acknowledgements Die bedanking moet ek in Afrikaans skryf, want dit is die taal van my hart, en die mense wat ek moet bedank, het elkeen ‘n plek daar. Eerstens my wonderlike man en dogtertjie. Liefste Marié, jy is die sonskyn in my lewe. Jou vrolike laggie is die mooiste klank op hierdie aarde en jou sprankelende oë, die mooiste gesig. Ek is jammer dat jy vir so lank een van die eerste kinders by die skool moes wees – veral in die middel van die winter. Ek is jammer dat ek party aande nie vir jou ‘n storie kon lees of soms nie na jou stories geluister het nie. Jy is die beste geskenk waarvoor ‘n ma kan vra. Frik, jy is die wonderlikste man in die wêreld. Jou geduld en ondersteuning het my deur die donker dae en nagte gedra. Dankie dat jy altyd bereid was om die kos te maak, die inkopies te doen, vir Marié stories te lees, kortom pa en ma te wees, sonder om te kla of te verwyt. Vergewe my my ongeduld met tye en afwesigheid die laaste weke. Jou wysheid en liefde dra en behoed my. Dankie ook aan my ouers, Steve en Marié. Dankie vir die jare se ondersteuning en aanmoediging. Dankie dat julle altyd in my glo. Julle voorbeeld het my geleer om altyd vol te hou, altyd my beste te gee en nooit op te hou groei nie. En natuurlik aan my promotor, Anton van Niekerk. Ten spyte van my lang stiltes en stadige vordering het jy by my gestaan en bly aanmoedig. Ek is baie dankbaar daarvoor. Sonder jou insig en leiding sou ek sekerlik nie die paal gehaal het nie. Laastens aan my pasiënte wat my inspireer en soveel leer. Veral aan Johann Potgieter, waar jy ook nou mag wees. Jou ongelooflike moed en kalm gees sal altyd by my bly. 7 Stellenbosch University http://scholar.sun.ac.za Table of Contents Introduction....................................................................................................................
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