Autonomy: a short history of a big idea

By Michael Cook

“The strongest arguments in favour of physician-assisted suicide [PAS] are respect for autonomy, justice, compassion, honesty, individual liberty and transparency.” This is a sentence drawn from a press release issued by the European Society of Anaesthesiology, which debated PAS at a conference in Geneva earlier this month.

But it could have come from almost any medical ethics textbook. Respect for autonomy is a cornerstone of contemporary bioethics – and like all good cornerstones, it is firmly fixed and seldom tested.

However, an historical account of the notion in the journal Medicine, Health Care and Philosophy questions whether it is necessary or coherent or beneficent. Toni Saad, of the Cardiff University School of Medicine, in Wales, concludes that:

it is not necessary to embrace an ethic of autonomy in order to guard patients from coercion or paternalism, and that, on the contrary, the dominance of autonomy threatens to undermine those very things which have helped doctors come to view and respect their patients as persons.

This is a daring attack on a deeply entrenched principle, one which will require many salvos to demolish, but Saad makes a good fist of it.

First, he points out that the Hippocratic tradition in ancient medicine contained the germ of the notion of the modern notion of autonomy; it was not completely paternalistic and chauvinistic. For instance, there is evidence that disclosure of information, choice of physicians, informed consent and medical truth-telling were all present in the practice of good physicians. “This suggests that a conscious awareness of the concept of autonomy is not always necessary for good medical practice.”

In the most substantial part of the essay Saad examines the Enlightenment legacy of Rousseau, Kant, and J.S. Mill. This is too complex and lengthy to summarise here, but the upshot is that the hallmark of authentic moral actions was free choice, not the content of the action.

Thus, logical inconsistency becomes the only immorality, and distaste for inconsistency the measure of morality; rationality has no content beyond itself; ethics is reduced to reason and must therefore remain agnostic about what is good and evil.

He then moves on to the post-War development of bioethics, which originated in the worlds horror at Nazi atrocities. The Nuremberg Code is a key document which stresses the importance of free and informed consent.

A key figure in the bioethics of the 1970s was Paul Ramsey, who was “unabashedly Christian” and set the agenda for later developments – suggesting, too, that “autonomy” may not be needed as a guarantor of good medical care. However, his influence faded with the widespread popularity of the four elements of Beauchamp and Childress’s principlism in the 1980s.

They “emptied the words ‘respect’ and ‘person’ of their meaning, so that autonomy per se becomes that which is respected, not persons.” Although their framework appeared merely to enshrine conventional ethical views, Saad argues that it made autonomy central. It “possesses the seeds of its own destruction because so little cannot be justified by appeal to [respect for autonomy]” – from organ retrieval from living patients to limiting conscientious objection.

Although competing ethical traditions exist, respect for autonomy has quickly become the dominant ethical framework. Why? Saad fingers moral fragmentation:

Bioethics, with its emphasis on autonomy, is the inheritor of an increasingly thinning concept of human goods. Thus, the principle of RFA and its tendency to dominate contemporary ethical discourse is symptomatic of an atrophied conception of human flourishing, and a consequent shift towards formally rational debate. Since theorists cannot agree on what is good, they will reach for the few remaining available principles, and thereby lock themselves in to a formally rational and inevitably reductive debate. This is the ground upon which autonomy ethics flourishes. Indeed, nothing but autonomy can grow upon this soil, which means the inevitable decimation of diversity in bioethical discourse, and maybe even moral famine.

It is a fascinating essay which deserves to be widely read.

Editor’s note. This appeared at BioEdge and is reposted with permission.