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Autonomy in Medical Ethics After O'neill 127 J Med Ethics: first published as 10.1136/jme.2004.008292 on 28 February 2005. Downloaded from CLINICAL ETHICS Autonomy in medical ethics after O’Neill G M Stirrat, R Gill ............................................................................................................................... J Med Ethics 2005;31:127–130. doi: 10.1136/jme.2004.008292 Following the influential Gifford and Reith lectures by Onora O’Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that See end of article for authors’ affiliations it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and ....................... convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O’Neill in recommending Correspondence to: G M Stirrat, Centre for a principled version of patient autonomy, which for us involves the provision of sufficient and Ethics in Medicine understandable information and space for patients, who have the capacity to make a settled choice about University of Bristol, Bristol, medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it UK; gstirrat@blueyonder. co.uk against the patient–doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the Received 31 January 2004 dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate In revised form any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly 25 April 2004 Accepted for publication even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to 27 May 2004 consider mistakenly that unthinking acquiescence to a requested intervention against their clinical ....................... judgement is honouring ‘‘patient autonomy’’ when it is, in fact, abrogation of their duty as doctors. e live in the ‘‘time of the triumph of autonomy in independence or self-expression’’. She continues, ‘‘Kantian bioethics’’ in which ‘‘the law and ethics of medicine autonomy is manifested in a life in which duties are met, in are dominated by one paradigm—the autonomy of which there is a respect for others and their rights’’. Kant’s W 1 the patient’’. This is, perhaps, not surprising given that view of autonomy is not ‘‘a form of self expression’’, but ‘‘from the outset, the conceptual framework of bioethics has ‘‘rather a matter of acting on certain sorts of principles, and accorded paramount status to the value-complex of indivi- specifically on principles of obligation’’. Thus in Kant’s dualism, underscoring the principles of individual rights, account of moral autonomy ‘‘there can be no possibility of autonomy, self-determination and their legal expression in freedom for any one individual if that person acts without the jurisprudential notion of privacy’’.2 These were the reference to all other moral agents’’.8 O’Neill entitles this weapons required to attack and breach the citadel of medical ‘‘principled autonomy’’ (which we will contrast with paternalism that dominated the patient–doctor relationship ‘‘individualistic autonomy’’). According to Jennings,9 Kant http://jme.bmj.com/ until at least the middle of the twentieth century. One and others established that ‘‘morality requires a person to influential medical sociologist has argued that there is an assume responsibility for his or her choices, actions and important link between the ‘‘triumph of autonomy in decisions and to act on the basis of informed reason and American bioethics’’ and American individualistic culture autonomously held, principled commitments. Others in turn more generally.3 However, there are growing indications that must respect the moral agency and reasonable commitments a number of bioethicists are becoming less than comfortable of the person in this sense.’’ with this individualism.4 In this article we wish to argue that Individualism has, of course, honourable origins in on September 26, 2021 by guest. Protected copyright. the individualistic paradigm of ‘‘autonomy’’ is an aberrant the humanism of the Renaissance, the rationality of the application and we wish to address the question, ‘‘How are Enlightenment and the struggle for personal and political we to understand ‘autonomy’ in medical ethics after Onora freedom out of which our Western democracies sprang. O’Neill’s challenging Gifford5 and Reith lectures?’’6 However, in the late twentieth century, this led to the Much writing on the subject of autonomy fails to define operational concept that each of us carries our own the term and the way the authors are using it.7 Understood ‘‘quantum’’ of ethics—‘‘I have my ethics; you have yours literally ‘‘autonomy’’ is self-governance or self-determina- and neither should impinge on the other’’. It also means tion. Although originally applied by the ancient Greeks to that ‘‘rights’’ now tend to be claimed without any sense of city-states, philosophers extended the concept to people from reciprocal obligations and that ‘‘rights are multiplied, the eighteenth century onwards. Kant, in particular, gave assumed or attributed where they do not exist, replacing autonomy a central place and there it has remained. What the language of duties which oblige even where there are no has changed is the interpretation of ‘‘autonomy’’. O’Neill5 rights’’.10 In the opinion of Schneider,1 ‘‘The overwhelming believes that it has now become too individualistic. She weight of bioethical opinion endorses not just the autonomy reminds us that John Stuart Mill ‘‘hardly ever uses the word, principle, but a potent version of it’’. He considers that this autonomy’’ and when he does so refers to states rather than paradigm is sustained by the ‘‘assumption that autonomy is individuals. ‘‘Mill’s version of autonomy’’, she asserts, ‘‘sees what people primarily and pervasively want and need’’. Thus individuals not merely as choosing to implement whatever the dominant view of individualistic autonomy in much desires they happen to have at a given moment, but as taking recent liberal bioethics (and more generally in Western charge of those desires, as reflecting on and selecting among society) is that it confers a ‘‘right to act on one’s own them in distinctive ways.’’5 She also maintains that Kant judgment about matters affecting one’s life, without inter- never speaks of autonomous people or individuals and ‘‘he ference by others’’10 (our italics). Following O’Neill, we believe does not equate it with any distinctive form of personal that this individualistic version of autonomous choice is www.jmedethics.com 128 Stirrat, Gill J Med Ethics: first published as 10.1136/jme.2004.008292 on 28 February 2005. Downloaded from fundamentally flawed. We believe that medical ethics should In her influential book Autonomy and Trust in Bioethics5 (based always be set in the context of relationships and community. on her Gifford Lectures in the University of Edinburgh in 2001) We believe that, if patient individualistic autonomy is to be O’Neill maintains that ‘‘trust is not a response to certainty the sole criterion for decision making, the patient–doctor about others’ future actions’’. Indeed, ‘‘trust is needed precisely relationship is reduced to that of client and technician. when and because we lack certainty about others’ future O’Neill11 considers that ‘‘conceptions of individual autonomy actions’’. Thus, there is an inevitable element of risk in plac- cannot provide a sufficient and convincing starting point for ing one’s trust in someone or something that introduces a bioethics, or even for medical ethics’’. She concludes, ‘‘The vulnerability to any relationship of trust. Thus ‘‘trust’’, by supposed triumph of individual autonomy over other definition, requires faith that in this context is defined as principles—is an unsustainable illusion’’. ‘‘committing to that of which we can never be sure’’.20 This It might be argued that O’Neill’s critique of individualistic does not mean that trust should be placed blindly. On the autonomy has already triumphed in medical ethics and that contrary, trust should only be placed in a person, object or there is now no need for us to critique it further. John Harris organisation in the light of the best available evidence that he, provides a striking illustration that this is not so. In a recent she or it is trustworthy. Yancey reminds us, ‘‘a person who lives issue of the Journal of Medical Ethics (in which O’Neill five in faith must proceed on incomplete evidence, trusting in pages earlier argues that ‘‘contemporary accounts of auton- advance what will only make sense in reverse’’.20 omy have lost touch with their Kantian origins, in which the On what does trustworthiness depend? To be trusted one links between autonomy and respect for persons are well must, first, show that one is trustworthy. The most argued’’12) Harris claims that13: ‘‘Autonomy, the values immediately obvious criterion is ‘‘track record’’ or demon- expressed as the ability to choose and have the freedom to stration of competence. His England team mates trusted that choose between competing conceptions of how to live and Jonny Wilkinson would drop that goal in the last seconds of indeed of why we do so, is connected to individuality in that the Rugby World Cup Final because of their past experience it is only by the exercise of autonomy that our lives become in any of his prowess and despite the uncertainty caused by him sense our own. By shaping our lives for ourselves we assert our having already missed two such kicks in the match. A second own values and our individuality’’ (our italics). important criterion is the means by which competence is Schneider1 suggests that there are two current models of gained and attested.
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