Patient Autonomy and Paternalism
The concept of moral autonomy is the cornerstone of the reigning moral-theoretical paradigm in many areas of public discourse today. In the relationship between health care provider and patient, the paternalistic oath attributed to Hippocrates has been mainly abandoned precisely because the theory of paternalism, reflected in the oath, is at odds with the theory based on moral autonomy. This concept also provides a moral foundation for the classical theory of liberal democracy. Political philosophies cannot offer justifications of systems of government unless they are equipped with a moral theory or theory of justice. The liberal theory of justice is premised on the claim that each rational individual possesses an intrinsic moral worth insofar as he or she is capable of doing what we can call moral legislation. As an autonomous individual, I am capable to give the moral law to myself by engaging in rational deliberation. This is what moral legislation means. We will unpack this principle later, after we have provided some background about the scope of its applications.
The early systematic analysis and development of an autonomy-based theory was undertaken by Immanuel Kant in the 18th century. Given that the concept of moral autonomy is central also in the legitimatizing theory of constitutional democracy, we have an overlap between deep justifications in legal theory and the moral theory known as deontology (initially developed by Kant.) This is interesting because the distinction between legal and moral may then turn out to be not as sharp as we might think. This is a bonus for a political system: after all, laws can be criticized on several grounds - for instance, on the grounds of efficiency of application - but the most serious criticism of a law is that it is morally defective or "unjust." Convergence between an accepted moral theory and the the spirit of justification offered in legal argumentation is a sign of vitality for a political system. In liberal or contractarian systems like ours, arguments brought up in juridical theory and in the practice of jurisprudence in defense of an applicable concept of liberty tend to have a deontological character. For instance, a classic argumet in defense of privacy emphasizes the moral stake individuals have in plotting their own development which reflects the recognition of individuals as autonomous moral agents.
(In contrast, insofar as deference may be given to social or public policy considerations, the reasoning take on a characteristically consequentialist - specifically utilitarian character. This does not mean that there is a tension in the foundations. Although the two theories - deontology and utilitarianism - cannot be combined, it turns out, and are mutually at loggerheads, they find different spheres of application. This is possible because the moral claims or rights based on autonomy are not absolute. The deeper reason for this seems to be the plurality of individuals: no matter how high the moral stakes are in respecting my autonomy, they cannot justify interfering with an equal stake in respecting someone else's, anyone else's, autonomous developments. This collision opens the door, as it were, to areas in which tough choices are to be made: utilitarianism permits a quantified, even computational approach, to policy matters. For instance, a public work that benefits a greater number of people seems right in contrast to one that benefits a smaller number of people, other things being equal and given that individuals are presumptively equal in their initial moral claims. On the other hand, as is known, utilitarianism appears to run into difficulties when it comes to defense of individual rights: so, we are thrown back, from the policy domain back, to the sphere of inherent and "inalienable" rights and now the justification taken on a deontological character again. This pendulum back and forth between deontological and utilitarian thinking can be observed in court decisions - between liberty considerations, on the one hand, and justification of specific measures that apply when liberties are justifiably to be curtailed. For instance, one cannot use utilitarian arguments easily to uphold free speech claims but, given that there is justification for regulating free speech, utilitarian considerations may enter with respect to determining specific public policy measures. This oscillation between deontology and consequantialism reflects an interesting, perhaps also unsettling, feature of our moral intuitions: both theories seem to be getting something right about the criteria we need to apply in moral decisionmaking; and yet, the theories seem opposed to each other even to the point that combining them may well end up in inconsistency - although attempts at combining them have been undertaken. Let us not lose sight, though, of the basic point: the foundational moral principle in defense of liberty is deontological and, more specifically, it is ultimately the principle of moral autonomy.)
Let us look closely into the components of the moral autonomy principle (MAP):
- Moral worth inheres or is intrinsic to each individual. There is a catch: what do we mean by "individual" in the relevant sense? This will become clear as we talk of the preconditions for moral deliberation - what it takes to enter into decisionmaking about what the right thing to do is. The claim about the moral worth of each individual - insofar as he or she fulfills the preconditions - comes across as egalitarian, as it ought to be expected. It is not an equality based on need - notice that. It turns out to be a formal equality - with the word "formal" needing clarification. The emphasis for determining the preconditions for moral equality is on the capacity for moral deliberation (entering into moral decisionmaking.) The word "deliberation" pulls us toward the direction of a more radical version of democratic theory (think of the whole "demos" or people participating in collective deliberation or decision-making about what is to be done.) Yet, our principle stops way short of reaching democratic radicalism: it is rather anchored in individualism; it is the individual as such that is the carrier of the moral claim to being considered autonomous (not, for instance, the individual as constituted through collective participation.) Now, all this sounds very general - no content. This is as it ought to be, up to this point. The capacity to deliberate is rational for this theory. It is not, for instance, an ability to experience visceral empathy toward others. Rationality is considered universal or automatically accessible to anyone who, by definition, counts as a deliberative animal (an intelligent human) anywhere and under any circumstances. Needless to say, the theory comes under severe criticism by postmodernists, feminists, relativists and others who deny that there is one universal Reason. Why is reason given such prerogatives with respect to moral decision-making? We turn to this next.
- The relevant capacity for claiming moral worth is rational-deliberative. This does not pull toward an elitist direction. We are not talking about complex reasoning of which, for instance, only mathematicians or logicians may be capable in practice. This is not a Platonizing theory - one that prescribes as right rule by the relevant experts of reasoning. The rationality we are talking about is an ideal - like in the "reasonable person standard" of law - but it is widely accessible to all but those who are severely incapacitated and, as such, lack competency. A disturbing corollary of the theory - usually amended ad hoc in other versions of deontology - is that those who are indeed incapacitated when it comes to exercise of mental faculties are excluded from the "kingdom" of moral agents and moral decisions are to be made on their behalf without violation of their dignity. This is because moral dignity or worth is itself dependent on the basic rational competency - at least, this is the initial view. To understand why such primacy is accorded to reason, let us consider the following. (Other ways of explicating Kant's theory are available - it is not an easy theory to analyze...) What makes us uniquely - within the animal kingdom - capable of moral deliberation seems to be our ability for higher-order, directed thinking. What do we do when we try to figure out if an act is morally right or morally wrong? If we think of ourselves as acting in accordance with our physico-chemical impulses, we cannot find what is different in us from other animals! So, this doesn't work. But let us then think of ourselves as acting rather in the realm NOT of nature but of freedom. What does this mean? We are thinking of ourselves as agents capable of morally significant action: this is free, motivated, action. It is not instinctive or deterministic. Suppose that we don't know how to put content into our decision-making efforts: what IS the right thing to do? Yet, we are already capable of engaging in moral deliberation. Notice how "deliberation" has already come up. Now, to determine what the morally right thing to do is, we would rather want to know what is RIGHT - not what is prudent or smart or practical or efficient but what is MORALLY right. The model for moral right is willing to do something only because it fits the moral standard and for NO other reason whatsoever. We are capable, then, of a respect for the MORAL LAW. This respect is more like the awe we feel when we check out the solution of a mathematical problem. It is not a feeling like when we feel pity or love. This may sound odd but remember: our feelings put us back with the non-deliberative animals - they are instinctively conditioned, naturally guided responses; but, instead, it is deliberative capacities we need to apply. To determine, then, what content is to be put into our action - what the MORAL LAW is - we need to use REASON. This fundamental rational capacity bestows moral worth to us all. This shows that we have the initial ability to give the moral law to ourselves - each one for himself or herself - which is called MORAL AUTONOMY. We are talking about the moral law, not moral laws: the view is not subjectivist relativism! The details about how to determine what the moral law is have to do with universalizability: if we take a maxim (a suggested moral principle, about which we don't know if it is a good principle or not), we apply a test on it: we take it as applying universally with no exceptions whatsoever: as we do this, we check for possible logical contradictions emerging - and if they do, we have a BAD moral principle that has to be rejected. Once again, the emphasis on rationality comes across: we track logical consequences that follow from adopting principles.
- Given this capacity for moral autonomy, it is always morally wrong to treat anyone who is a moral agent as if he or she were a means to ends he or she has not chosen. This treatment amounts to depriving the autonomous person of autonomy: someone who can rise to the moral law - and, because of that, is a member of the ENDS - is treated like a means. To be a member of the "kingdom" of ends means to be able to make moral decisions about everything. In liberal democratic theory, this founds the so-called developmental argument: liberty is morally a right because it is the way in which autonomous moral agents relate to objects of choice. If a woman is forced to marry someone against her wishes, as the practice is in traditional societies, she is treated as if she were a means to ends she has not chosen even though, as rational agent, she is essentially autonomous - capable of making moral decisions by herself. EVEN if the ends toward which she is manipulated is for her own good, she is still treated as a means and is not allowed to be properly a moral agent who gives her goals to herself. Notice the contradiction in the practices of the traditional society: the person so treated IS autonomous, by definition, and yet she is treated by the moral theory of the society as not being autonomous insofar as she has her choices made for her. It is like having a language in which "triangle" is declared to have four angles but without changing the meaning of the word! The oppressed woman in our example is usually deprived of legal rights but with respect to MORAL rights, if the Kantian theory is correct, she cannot be dispossessed of her inherent moral worth given her autonomous capacities - and yet she is dispossessed in the name of a presumed moral view.
- Being morally autonomous does not mean that anything I freely and deliberatively choose to do is right. I can surely err. Recall what was said about universalizability above. My moral maxim - my personal moral principle - may fail when universalized and still I might be unable to detect it. Then my actions are wrong but, still, I should not be coerced into doing the right thing. This is a key point and comes into play in many applications. For instance, a rationally competent, morally autonomous patient may autonomously refuse life-saving treatment. Let us assume, furthermore, that the treatment itself is safe without a high probability of negative consequences or side effects. What this patient does can be criticized as morally wrong on solid grounds (universalizing the maxim this patient seems to be following would show that the maxim is not defensible); and yet it is still wrong to coerce the patient into having the treatment done to him against his competent expression of what he wills to do. Why is this so? We are not using utilitarianism to compute how benefits are distributed by contemplated actions. The prohibition of intervention against the autonomous person is rather absolute: since they are autonomous, or capable of making moral decisions, treating such patients as if they were not autonomous is wrong.
- Could we say that refusal of treatment under such circumstances actually shows that they lack the competency required for rational deliberation - so the patient might not be morally autonomous after all? This is an important question we will be return to.
- What if others are affected by the patient's decision - assuming that competency of the patient is not at issue? Here we have a different situation. Restricting the patient's liberty to choose is not PATERNALISM. By definition, paternalism is a restriction of liberty undertaken with a view to promoting the benefits of the person whose liberty is so restricted. What about the prohibition against treating the person as a means to ends not decided by this person? Once again, the situation is different when others are affected by decisions made by them because the ends of those other persons are entered into the overall scheme of things. Classical deontology has difficulties resolving certain complex situations like the one we just complicated. Autonomy may still trump: consider, for instance, the case in which a patient's refusal of safe but life-saving treatment is going to have adverse effects on her family; in the context of the physician-patient relationship, respect for patient autonomy seems to be come on top...This is not a narrowly legalistic issue - after all, intervention without express consent, under the circumstances, may constitute illegal assault or battery; the issue is moral as ought to be clear by now.
- By the same token, of course, the patient cannot request actions undertaken by the health care providers, which violate the autonomy of the health care provider himself. For instance, a patient in deep agony and facing a future steeped in suffering may contemplate termination of life-sustaining treatment but he does not have a moral claim that the physician or nurses would pull the plug if this goes against their moral choice (because this violates the moral autonomy of that health care provider.) In a case like this, by the way, classical deontological theory may draw a blank (as it does really with moral dilemmas in general.) A moral duty to sustain life is clearly supported by deontology - on this ground, the patient's decision to seek termination is morally wrong; the patient cannot treat himself as a means or instrument either (keep this in mind.) On the other hand, the indignity of a human life deprived of all purpose besides agonizing suffering may also find deontological support. On that account, the patient would have a moral claim to termination on deontological grounds. Here we come across a theoretically unpleasant case: a moral dilemma - and deontology has no way of resolving them. Current textbooks of applied ethics tend to adding weight in favor of the termination decision - the justification provided for this may not be "purely" deontological; subjective preferences or value-choices may be privileged, for instance, and this is not a deontological move. Of course, one should not expect any one theory to have satisfactory or consistent solutions across the board. The value of moral autonomy, however, remains foundational even if we don't rely entirely on the moral philosophy of Kantian deontology.
Other Principles in Tension with Moral Autonomy
The principles of beneficence and non-maleficence compel moral agents, respectively, to do good and not to do harm. Given the ineluctable limitations on ideal requirements imposed by the empirical world (scarcity of resources, time and space constraints, etc.), these principles are to be taken to mean, respectively, do as much good as possible and avoid doing harm to the fullest extent possible. If the patient's moral autonomy is respected this could entail that the health care provider does not live up to the fullest potential of doing good and avoiding to do harm. The patient may wish to pursue a path of action that leads to harm to him or her. We are to assume that issues of competency on the part of the patient do not arise. It is still possible that a reasonable patient attributes values in such a way that, for instance, she places a higher valuation on certain aspects of quality of life than to preservation of life itself. Therefore, she refuses treatment and she does so without, by so doing, showing herself to lack the requisite cognitive capacities that establish competence for purposes of moral autonomy. From the standpoint of the health care provider, the chosen path of action leads to a situation in which preventable harm to the patient is not prevented and foreseeable and feasible benefit to the patient is not bestowed. It appears that the principles of beneficence and non-maleficence are both violated.
Apparently, the principles are to be ranked in such a way that autonomous exercise of choice trumps or overrides the other two principles. This is consistent with the developmental argument in support of liberty: within a delineated private sphere (defined so that maximal liberty opportunities are available for everyone else as well), the autonomous moral agent has a constitutive moral entitlement to choosing how to conduct their actions, how to assign valuations to alternative life plans, and how to elect the means for the furthering of their developmental goals across time. The two principles related to benefits and harms do not conflict with moral autonomy insofar as they are ranked as secondary to the autonomy principle. In the instance in which the patient freely chooses to pursue a path that maximizes benefits, and maximally prevents harms, to her, we have a point of perfect convergence between the autonomy and the benefit-harm principles. This shows that the two can possibly be fulfilled together.
Reliance on the benefit and harm principles is not necessarily paternalistic. Consider, again, the case in which the patient autonomously elects a path that conduces to benefit. There is no restriction of liberty of the patient in this case, while the benefit principle is fulfilled. This shows that the two do not necessarily conflict - as the case would have to be to have a fundamental incompatibility between them. It follows that the benefit-harm principles are not inherently paternalistic since their full application does not necessitate restriction of the benefiting party's liberty.
Utilitarianism would support some version of the benefit/harm principle. When benefiting one patient may harm another, we have a case in which the harm/benefit principles themselves stall in application. How should we apply those principles? The problem may be residing in the vagueness attaching to the principles: it sounds that benefit and harm are either to be bestowed or not to be bestowed to a patient but vagueness means that it is rather a matter of degree whether a benefit can or cannot be bestowed to the patient. Utilitarianism overcomes application difficulties by shifting to the overarching viewpoint of the whole: the action that maximizes the benefit, properly defined, of the greatest number of people is the action that is morally obligatory to undertake for the version of the theory known as Act Utilitarianism. In adjudicating clashes between benefits/harms distributed to patients, Utilitarianism compels action that maximizes the overall benefit and minimizes the overall harm. Arguably, this view does not abandon the benefit/harm perspective in ethics; but it does socialize it, as it were, in that it brings into the relevant moral universe a fictitious aggregate person as a morally relevant participant. Once again, it appears that considerations pertaining to benefit/harm distributions find more intuitively appealing support in Utilitarianism, while, on the other hand, considerations about irreducible individual human dignity and integral decisional autonomy are supported by a deontological theory - some version of the theory constructed by Immanuel Kant.
Why Has Autonomy Emerged Triumphant?
The emphasis on individualism is inherently entwined with the recognition of autonomy as an integral and fundamental value. Autonomy is defensible as a moral value only if the moral center of the universe of values is the individual. It is theoretically possible to have an inegalitarian version of autonomy - if restrictions are defended as to who is able to function as an autonomous individual in the normative sense of the word. It is not coherent, however, to have both autonomy and a rejection of the individual as ultimate normative agent. In a sense, and in spite of the Pietistic credentials of Kant himself, the emphasis on autonomy is at odds with religious emphasis on the involvement of the whole community of faithful - and with the religious doctrine that lays the source of all value at the feet of a divine being. At a minimum, an argument is needed to the effect that divine license has been granted for exercise of individual moral claims. This kind of argument we find in the chapter on property in John Locke's Second Treatise of Government. Additional arguments may draw attention to a supposed futility of imposing faith that is not freely and individually entered into. The possibility of error, which arises in individual choice and relative to the doctrinal truths of religion, has also to be justified.
The Marxist view of the history of ideas seeks economic power behind the "superstructural" excrescences of ideological and theoretical constructs. The desideratum for the market economy is to buy as cheaply as possible and to sell as expensively as possible. This applies to labor too - and this, again, requires a deracinated existence that takes the individual, and not the whole community, as bargaining party in the labor market. This is characteristic mercantile thinking and it is inevitable that a philosophy defending this approach would emerge in the wake of the American and French revolutions in which the mercantile and moneymaking classes finally seize the political power which had been denied them - in spite of their burgeoning economic preponderance - by the decrepit system of an increasingly indebted nobility.
Could one make the case that the emphasis on autonomy has intuitive support and it was only a matter of time before the notion became paramount? This is not easily defensible as a position. In hierarchically structured societies, lower-caste individuals simply do not see themselves as capable of exercising decisional authority even in matter affecting their own destiny. It could be argued that their common sense has in this case been denied them by the propaganda they have been subjected to - but this begs all kinds of questions as to whether there is a universal common sense that is authoritative in moral issues, what criteria and signs we are to use to canvass it, and whether there can be common sense even if its views are inert or unrecognized.
The most sophisticated defender of moral autonomy is arguably Immanuel Kant. It may be noteworthy that his moral theory is too inflexible to find wide application. Whether this casts doubts about autonomy-theories or about all moral theories is an interesting subject. Under the influence of the theory of social contract - which is mostly inflected toward the direction of individualism - Kant developed his moral philosophy. He claimed as primary influence the work of the most radical thinker of the social contract tradition, Jean Jacques Rousseau. Remarkably, Rousseau managed to smuggle in an unexpected communitarianism into a theory, of the social contract, which begins with recognizing as ultimate value individual self-preservation. If Rousseau's claims are to be taken seriously, he showed that when pushed to its ultimate logical conclusions, the view of individual self-preservation compels choice of a communitarian system in which extremes of wealth and poverty are absent and communal, all-inclusive deliberation elicits the morally right decision as self-interested choices cancel each other out more and more to reach harmonious choices that are to the common interest. This accords with the Aristotelian view - that a just political system must be ultimately promoting the common good. Market ideology, in its classical version, did not deny this but the deliberative or decisional means are supposed to remain inextricably bound to individual self-interest. If Kant has provided a more sophisticated defense of autonomy, it is also the case that he deradicalized the Rousseauan critique of bourgeois or Lockean liberalism. In practice too, an emphasis on autonomy appears as radical when contrasted to inegalitarian, elitist, liberty-restrictive theories but it actually comes across as far less radical when compared to the theories from the collectivist left. Of course, we need to make sure that we are not begging the question as to what we are to understand as radical. Rousseau's theory is radical in the sense that its principles allow both construction of a theory and critique of the alternatives. In the case of Kantian liberalism, on the other hand, the sophistication is rather metaethical -- it is universalizability that gives Kantian ethics its distinct punch. This methodological approach to how to construct a moral theory can hardly serve as a critique of the content of alternative theories. Indeed, certain assumptions may need to be made about human nature - that human beings are, for instance, minimizers of troublesome consequences expected to follow from their actions. Rousseau, on the other hand, shows how to proceed even without making any assumptions about human beings other than their distinct animality - which is a common denominator of all these theories anyway. This lends Rousseau's theory its radical punch: Rousseau can claim that the attributes given to human agents by contractarian theorists are derivative from an unjust social arrangement and they can be used, as they are, to justify political systems only at the pain of circularity.
It is difficult for someone raised in a western society to even contemplate alternatives to autonomy. Only when examples of communitarian views common to other cultures come up that the notion that autonomy is not globally self-evident as a value dawns. The principle of autonomy is tested when patients want to relinquish decisional autonomy to the expert; or when the patient does not want to know what she must in order to have her autonomy intact for purposes of decisionmaking; or when other parties are made to acquiesce to self-destructive choices by the patient that seem to defy common sense without running into an extreme that would establish patient incompetence; or when surrogacy is established in cases in which it is not clear what the patient may have done under the circumstances. From the point of view of consequentialist thinking, it appears that the greatest common good may be compromised by reliance on privileged autonomous decisions.
© 2014 Odysseus Makridis