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Dignity, patient’s autonomy and mental illness Eduardo Henr ique Rodrigues de Almeida Abstract Human dignity, intrinsicall y li nked to autono my, is vulnerable in situation s of seve re mental disor der, either to participate in medical research or to participate of therapeutic decision s. The author discuss es the con cept of dignity, the principle of autono my and the infor med con sent, and, by rev iewing the li teratur e, sugg ests that ethical action is the con stant exercise to identify when and ho w it is easier to disregard dignity and avoid doing it. He con cludes by stress ing that to deny autono my to others, simply because on e is in a position to do so is to respect his dignity. Att ention shou ld be paid to the fact that paternali sm and beneficence are no t always goo d solution s for the mentall y ill. Key words: Personal autonomy. Bioethics. Vulnerability. Informed consent. Mental health. Mental competence . Man is he and his circumstances Ortega y Gasset How to deal with autonomy issue when one deals with subjects who were destitute of all and any possibility of its Eduar do Henr ique Rodrigues use if they are labeled mentally ill? In view of this limitation, de Almeida apparently insurmountable, this work proposes to discuss two essential Physician by the Federal University of Minas Gerais aspects: mentally ill patients’ capability to exercise their autonomies in (UFMG) Medical School, specialized in Labor Medicine, face of therapeutical possibilities, and the inclusion of these in medical Medical Clinic, and research groups, under the risk of abuse for being a vulnerable group . Gastroenterology, working in his doctoral degree in Bioethics at Reflection will point still toward the issue of treatment access, the University of Porto Medical considering mentally ill who are without access to appropriate School, Portugal, medical expert at Social Security INSS/MPS ) in therapeutics would not have their autonomy affected in double . Belo Horizon te, Minas Gerais, Brazil Revista Bio ética 2010; 18 (2): 381 - 95 Dignity : principle that defines human Dignity is a quality inherent to all human being beings, as moral beings, and just to these, for being completely inseparable of autonomy for AThe notion of dignity as intrinsic and the exercise of practical reason . À As they common feature to every human being exert autonomously their practical is relatively recent. History shows that reason, human beings build different human being’s primacy was not personalities, each absolutely individual extended always to all humans. Slavery and irreplaceable . Consequently, dignity demonstrates this, reigning both in would be inseparable from autonomy to exert practical Oriental civilizations and in classic reason, and for this reason is that just humans dresses European Antiquity, as well as up on dignity . persecutions promoted by the Holy Inquisition, in which discrimination was The great legacy of Kantian thought for human notorious and, usually, accepted rights philosophy is the equity in attribution of dignity. pacifically by legislators, historians, Considering that freedom in the exercise of the religious people, and philosopher at the practical reason is the sole requirement in order to a time . being dresses himself up on dignity, and that all humans enjoy this autonomy, one has that human The notion of human being’s dignity condition is the physical support needed and rests in his real being and in his sufficient to dignity, independently of any type of capability of being able to be, not been social recognition . For Kant, human being is an restricted just to what effectively one absolute value, an end in itself, because is gifted does out of this capability. Thus, one with reason. His autonomy, for being rational, is considers it as inherent attribute . Human the root of dignity, as it is what makes Man an dignity is, then, the acknowledgement of a value; end in himself 2. is a moral principle based in the usefulness of the human being, and not in his use as a means . Principle of autonomy This notion, since it is proper of human Etymologically, the word autonomy derives from condition, is considered also as inalienable autos, self, and nomos, law . One of the that cannot be taken away or suppressed 1. theoretical basis for ellaboration of the Equity among human being in attribution principle of autonomy derives from John of dignity bases the philosophy of Stuart Mill’s thought , for whom the individual human rights. It is from this value that is sovereign over himself, his body and mind. basic human rights derive . But, in Kantian view, autonomy is the power of the self over oneself – the freedom -, exerted ÉIt is usual to see the first enunciation of the dignity principle attributed to Imma nuel Kant, for who dignity is a value that covers all that which there is not price, that is, it is passable to be replaced by an equivalent . In Kantian thought , 382 Dignity, patient’s autonomy, and mental illness by the mediation of a law (nomos) that reason education or if he lives deprived of public order. imposes on itself. Moral occurs from this self-imposition. Equally, primary health care is a condition to Therefore, according to this proposition, autonomy and exercise autonomy 4. freedom are solidarian concepts, but not coincident. Whoever does evil acts freely, but without autonomy, The Belmont Report 5, which established the one submits freely to that part of his being that bases for adequacy of research ethics in the effectively is not free of his instincts, passions, United States (USA), designed autonomy as weakness, interests, and fears 3 , forgetting both law Principle of Respect for People. In this and its reflection in moral conscience . perspective, it proposed that autonomy incorporates, at least, two ethical An autonomous person is an individual convictions : the first one, that individuals capable to deliberate on his personal should be treated as autonomous agents; objectives and to act toward this the second one, that people with decreased deliberation, considering moral values from autonomy should be protected . Thus, one the context in which he is inserted. An divides the issue in two separate moral autonomous individual acts freely in requirements : that of recognition of autonomy, accordance to his own plan, in and that of protecting those with decreased analogous way to an independent autonomy . country that manages its territory and establishes its policies . To r espect Respect f or people with autonomy is to valuate consideration about decreased autonomy opinions and choices, avoiding, in the same way, the obstructions of autonomous subject’s action, Ar isto tle and Saint Augustine admitted the except if they are clearly harmful to others . distinction between things, animals, and human being 2 . Departing from premises coming from To show lack of respect toward an distinct conceptions of the world, both autonomous agent would be to not consider his recognized in human beings unique qualities judgments, to deny the individual freedom to act based that distinguished them from the others. on them or to omit needed information in order to a Currently, one considers that the fundamental judgment can be made when there are not convincing difference between human being and the other reasons for it. Ch arlesworth goes beyond and he animals is not in affectivity, but rather in the introduces the social perspective in defining capability to think symbolically, to represent individual’s autonomy, pointing that this may lead to and to project contents of conscience, using the own notion of citizenship . And he states that them in creation of human culture 6. nobody has the capacity to develop personal Consequently, conscience, is one of the freedom and feeling autonomous if he capabilities of human cognition, it is valuated as anguished by poverty, deprived of basic essential component of that which characterizes humanity – as one gets from Kant’s reasoning . Revista Bio ética 2010; 18 (2): 381 - 95 According to this formulation, conscience the inter-relational process in society . could be classified as the a priori for the Thus , considering this, how do we exercise of practical reason. Associated to attribute this same humanity to those notions of autonomy and dignity, its existence who are deprived of this relational would constitute, therefore, in prerequisite to existence, of this materialization of qualify humans as moral beings. Thus, it would themselves while persons, either be only in consequence of it that these would be because they never had it, as the case embodied of dignity. But, if it is conscience that of the newly born, or because they fundaments dignity, autonomy, and freedom, have lost it in consequence of health how can we classify those mentally conditions ? incompetent or those who, in reason of their age or health condition, are taken as incapable EmIn reply to such paradox, one may argue to exert their autonomy ? Would they stop that the prerequisite of conscience and, being humans because they are deprived of consequently, the attributes of dignity and moral full use of their mental faculties ? Departing autonomy should be understood as inherent to from such premise, both very young human species, biological characteristics of the children and the sick destitute of full use of Homo sapiens, independently of their their conscience could not be classified as manifestation in plenitude in each specific human being . humanly dignified 2. That is , human dignity would be an attribute of the potential human for the exercise of practical reason . The deadlock generated by unilinear One may conceive that, in this perspective, even application of this rationale, which those deprived of full use of reason may be associates mistakenly humanity to entitle to it, being, thus, carriers of the same reason, establishing that the first is a essential dignity, as well as the same intrinsic function of the second, deepens itself and inalienable rights than the others right .

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