Autonomy and Beneficence Revisited

I have previously argued that if someone asks me to buy him cigarettes and I was not going to be significantly inconvenienced that I have reason to do so. I assumed that he was an adult fully aware of the dangers of smoking. I am a non-smoker and believe smoking is harmful. However I also believe in giving precedence to respecting autonomy over acting beneficently. Recently a posting by Michael Cook in bioedge has caused me to question my position. Cook considers the case of a North Carolina woman called Jewel Shuping. Ms Shuping wasn’t born blind but was convinced that she was meant to be blind.  According to her doctors she had Body Integrity Identity Disorder. A psychologist gave her some counselling and after this failed gave her some eye-numbing drops before washing her pupils with drain cleaner. Cook asks was the psychologist right to destroy his patient’s eyesight even if she freely requested him to do so and was happy with the result of this treatment? The case of Shuping is an extreme one, however let us assume I am a carer for someone who becomes housebound and unable to buy the cigarettes he had previously enjoyed. Let us further assume that I buy these for him for a number of years and that eventually he develops lung cancer. In this situation am I partly to blame for his condition or have I only been respecting his autonomy? In this posting I want to examine the way in which we should respect someone’s autonomy. This examination is important for as Cook points out it has wider implications in difficult contexts for informed consent such as gender reassignment surgery and euthanasia.

Why did I argue that if it didn’t inconvenience me that I should buy a smoker a packet of cigarettes when he asked me provided he was an adult and fully aware of the dangers involved? I argued by doing so I was respecting his autonomy. Most people would object that my buying someone cigarettes has nothing to do with respecting autonomy. Respecting someone’s autonomy to most people simply means not interfering with someone doing something he cares about provided that by so doing he doesn’t harm others. If this is all it means to respect autonomy then respecting a smoker’s autonomy gives me no reason to buy him cigarettes when he asks me to do so. Let us accept informed consent is based on respect for patient autonomy. It then also follows that Shuping’s informed consent gave her psychologist no reason to acquiesce to her wishes. He might of course thought he was acting beneficently.

I now want to argue that the account of autonomy outlined above is an incomplete one. I will argue that a more complete account means that someone’s autonomous wishes must carry some weight for me. Let us suppose someone asks me to do him a favour and that doing so would not significantly inconvenience me. If I respect him I must feel it would be better to satisfy these wishes, provided by doing so I do no harm. If this was not so I would be indifferent towards him. Being indifferent to someone is not compatible with showing respect. At this point it might be argued that satisfying someone’s wishes has more to do with acting beneficently towards him than respecting his autonomy. However I would reject such an argument. I can act beneficently towards my dog by satisfying his needs but this doesn’t mean I respect him. I may of course love my dog but love differs from respect. Respecting someone as a person means accepting him as the sort of creature that can determine his own future. Respecting someone as a person means accepting what he determines to be his wishes must have some sort of weight for me. If I see someone as the sort of creature who can determine his own future but give no weight to his wishes then I am indifferent towards him rather than respectful. It does not of course automatically follow on from giving weight to his wishes that I have to satisfy them. Doing so might may harm others or cause me significant inconvenience. However it does follow that if I respect someone as a person and can satisfy those of his wishes which do no harm others without any significant inconvenience that I have reason do so. It further follows a more complete account of autonomy requires satisfying someone’s autonomous wishes provided these wishes do no harm to others or cause significant inconvenience.

Let us accept this more complete account of autonomy. If we accept that informed consent is based on respect for autonomy then I would suggest Shuping’s psychologist did have reason to acquiesce to her demands. It might be objected even if Shuping’s desire did have some weight him that her psychologist should not have acted as he did due the harm caused. Cook poses the question,

“Was the psychologist right to destroy his patient’s eyesight if she freely requested it, was happy with the treatment, and was living in psychological torment because she could see.”

Let us assume that Shuping would have been satisfied if the psychologist had blinded her but that he didn’t do so. Perhaps he believed his refusal to act was in her best interests. However if he did this he might be accused of epistemic arrogance. Moreover he might be accused of failing to respect her autonomy because he is failing to see her as the sort of creature who could make her own decisions. If the above is accepted then when respecting someone else’s autonomy requires that ‘the doing no harm condition’ should be replaced by ‘doing no harm on balance’. At this point it might be objected that such a concept of autonomy is far too demanding as people cannot always decide what on balance does no harm and we should retain the simpler condition of doing no harm.

I now want to argue we should accept the condition of ‘doing no harm on balance’. Let us assume that embedded within our thicker account of respecting autonomy is the simpler Millian account. Let us assume our smoker makes an autonomous decision to buy cigarettes. It follows that if I respect his autonomy that I should not act to stop him buying cigarettes by hiding his wallet according to the Millian account. Now let us now assume that he has broken his leg and that it would not inconvenience me to buy him the cigarettes. However I believe the cigarettes will cause him harm and refuse. In both scenarios I can prevent this harm by refusing to buy cigarettes when he has broken his leg and by hiding his wallet when he hasn’t. In both of these scenarios the outcome doesn’t change. If I hide someone’s wallet then I am acting to block him from exercising his autonomy. And if I refuse to buy him cigarettes I am omitting to act. A discussion of autonomy is an unusual place for the act’s/omissions controversy to occur. Does the difference between acts and omissions apply in this context? Indeed is there any real difference between acts and omissions in practical deliberation, see Julian Savulescu’s posting in practicalethics . In both of the above scenarios we are aware of the effects of our choice of behaviour. Christine Korsgaard argues that “choosing not to act makes not acting a kind of acting, makes it something that you do.” (1) I would suggest provided Korsgaard is correct then if someone chooses to act or chooses to omit to act that there is no meaningful difference between acts and omissions. It is still possible that acts and omissions might differ provided ones actions are ones he is fully conscious of and are omissions are unconscious choices. However is such a difference one between acts and omissions or a difference between degrees of consciousness concerning our behaviour? The above suggests to me that when it comes to respecting autonomy there is no meaningful difference between acts and omissions. It follows if I believe smoking will harm the smoker but refrain from hiding his wallet but refuse to buy him cigarettes I am acting inconsistently.

What conclusions can be drawn from the above? Firstly that a purely Millian account of autonomy is an incomplete account. A more complete account means that respecting someone’s autonomy requires that one must sometimes act beneficently towards him by attempting to satisfy his desires provided so doing does not harm him on balance and does not cause significant inconvenience. Autonomy and some forms of beneficence are linked. Of course I accept that someone might have other reasons to act beneficently which are independent of respecting autonomy. Secondly it follows I should buy the smoker his cigarettes. Lastly it would seem Shuping’s psychologist acted correctly. I am somewhat reluctant to accept this conclusion. Perhaps in cases in which the stakes are so high there must be some doubt as to whether one is in fact causing no harm on balance and the precautionary principle should be applied. Nonetheless in spite of my reluctance I am forced to conclude that provided he was sure he was causing no harm that on balance Shuping’s psychologist was acting correctly.

1. Christine Korsgaard, 2009, Self-Constitution, Oxford University Press, page 1.