In this posting I want to investigate what we mean by autonomy and the
relationship between autonomy and beneficence. I will firstly examine two
different accounts of autonomy. In order to do so I will briefly outline the
differences between a content neutral account of autonomy and a substantive one.
I will then raise some difficulties with accepting a substantive account of
autonomy. Next I will examine the relationship between a content neutral
account of autonomy and acting beneficently. I will conclude that preference
should be given to respecting autonomy over acting beneficently when these two values
clash. I will then consider what specifically makes rape and slavery so wrong
to support my conclusion. Lastly I will examine the implications of accepting
this conclusion for the doctrine of informed consent, the age at which someone
should be able to vote and the right of the disabled to make their own
decisions.
John Stuart Mill defined the only way power can be rightfully
exercised over another.
“The only purpose for which power
can be rightfully exercised over any member of a civilized community, against
his will, is to prevent harm to others. His own good, either
physical or moral, is not a sufficient warrant.” (1)
Mill’s definition can be used to provide a definition of a
content neutral account of autonomy. An autonomous person should always be free
to exercise his will freely, provided this exercise doesn’t harm others. Such a
definition of autonomy might be classed as a primitive or basic account. In
what follows a basic account of autonomy will refer to a Millian account It
might be suggested that advances in technology and medicine mean that such a
basic account is an outdated one. It might be further suggested that these
advances mean a more substantial account of autonomy is required. A substantive
account. A substantive account of autonomy places some constraints on what an
autonomous person can autonomously choose even when his choices don’t harm
others. For someone’s decision to be autonomous it must accord with certain
accepted norms in addition to the norm of not harming others.
I now want to present two arguments against adopting a
substantive account of autonomy. My first argument will suggest that adopting a
substantive account of autonomy would mean that autonomy becomes a superfluous
concept. Let us consider a substantive account of autonomy in which someone’s
decisions are only accepted as autonomous ones provided they would be regarded as
reasonable by most reasonable people. It might be objected it would be hard to
define which people are reasonable and what such reasonable people might find
to be reasonable. For the sake of argument let us ignore this objection. Why
does autonomy matter? It matters because it differentiates between those decisions
we should always respect and others. Let us accept that an autonomous choice
should be a reasonable one which would be accepted by most reasonable people.
In this situation it seems that to talk of respect for autonomy becomes mere
rhetoric. In this situation the concept of autonomy is doing nothing useful.
Someone wanting to know which decisions he must respect, by deciding if they
are autonomous decisions must first know that which decisions would be accepted
by all reasonable people. I would argue that this is all he needs to know in
order to respect someone’s autonomy. In this situation we simply don’t need the
concept of autonomy. I would suggest the same argument can be applied to any
other norms which might be applied in any other substantive account of autonomy
such as, someone’s best interests, acceptability to society or giving no
offence to religious standards. It appears to follow that those who advocate the
need for a more sophisticated account of autonomy, a substantive one, make the
concept of autonomy a redundant one.
I have argued above that respecting someone’s autonomy
cannot simply mean acting to further someone’s best interests because if we do
so the idea of respecting autonomy seems to do no useful work. I might act in
my dog’s best interests but this doesn’t mean I respect him or believe he is an
autonomous dog. Caring about someone or someone doesn’t seem to be the same as
respecting autonomy. What then is meant by respect? Respecting someone doesn’t
simply mean saying nice things about him for if this was so there would seem to
be no difference between respect and flattery. I would suggest respecting someone
involves admiration and that admiration is linked to valuing. For instance, if
I respect someone I might do so because I admire his honesty, determination or
his ability to make good decisions. I can admire someone because he is a
certain kind of person but what qualities do I admire and value if I admire
someone simply as person? What is a person? Christine Korsgaard argues
that a person is not identical to the human being the person supervenes on. She
suggests that,
“When you deliberately decide what sort of effects you will
bring about in the world, you are deliberately deciding what sort of cause you
will be. And that means you are deciding who you are.” (2)
It would be difficult to call anyone who was unable to make
any decisions a person. However, whilst the ability to make decisions is a
necessary condition for personhood it isn’t a sufficient one. Some who makes
all his decisions randomly or based on mere whims might be regarded as a wanton
according to Frankfurt (3). To be a person someone must have the capacity to
make decisions based on what he cares about or values. What does the above tell
us about respecting someone simply as a person? It would seem that if respect
involves admiration then respect for a person involves admiration for
a creature which can make his own decisions based on what he cares about.
I have suggested that respect, admiration and valuing are linked. I would now suggest
that respecting a person requires accepting his decisions. If we don’t do so,
our supposed admiration and valuing of him as the kind of creature who can make
his own decisions based on what he values, becomes mere rhetoric.
A defender of a substantive account of autonomy might object
to the above and argue that we can respect someone’s autonomy by respecting him
as the sort of creature that can make some of his own decisions. He might
proceed to argue we need only accept those of his decisions which don’t harm
his best interests. He might suggest that by doing so we then are still
respecting his autonomy, we are just according it less importance. I would
reject such a suggestion and. will now present two arguments to support my
rejection.
Firstly, let us assume that we can respect someone’s
autonomy by only accepting those of his decisions which are in his best
interests. It might then be argued that provided we do so we are still
respecting him as a person. But if we do so are we respecting someone simply as
a person or a particular kind of person? For instance, I can respect someone simply as a
person whilst at the same time failing to respect him as a particular kind of
person. I believe for instance that
he is a bad parent. It seems if we respect someone’s autonomy, by only
accepting those of his decisions which are in his best interests, that we are
respecting a particular kind of person. We are only respecting those persons
who make good decisions. Alternatively, we might only respect someone when he
makes good decisions. Does this matter? Let us assume we only respect the
autonomy of those people who make good decisions and that we should adopt a
beneficent attitude to those who don’t. I have argued above that what defines
someone simply as a person is his ability to make his own decisions, to
shape his life. It appears if we only respect the autonomy of people who make
good decisions that we fail to recognise some people simply as persons. Next
let us assume that we only respect someone’s autonomy when he makes what we
regard as good decisions. If we do so I can employ the argument used above and
question whether respect for autonomy really does any useful work. It follows
if we respect peoples’ autonomy by only accepting those of their decisions which
we think are in their best interests that either we won’t be respecting some
people simply as persons or we are only respecting people as a part time persons.
I now want to argue that if we respect someone’s autonomy
by only accepting those of his decisions which we believe to be in his best
interests that we aren’t acting in a fully caring way. It might be objected
that we are only acting in this way because we really do care about people. In
response I would suggest that in this situation because we decide what is in
someone’s best interests we might be accused of epistemic arrogance. However,
let us lay this suggestion aside and assume that respecting someone’s autonomy
in this way doesn’t mean we are exhibiting epistemic arrogance. I would still suggest
that this form caring is a deficient form. I accept if we act in such a way we
are acting sympathetically but I would argue we aren’t acting empathically.
True empathic care means we must care about what someone cares about rather
than simply what we believe to be in
his best interests. Someone might suggest sympathetic caring is as good as
empathic caring. I would reject such a suggestion. I can care about someone or
something sympathetically simply because I want him to flourish. This is the way
someone might care for a dog he loves. Empathic caring isn’t so simple. If I
care about someone empathically I must care about what he cares about in
addition to what I believe are in his best interests. Empathic caring is a more
complicated way of caring than caring based on sympathy. However, because
something is more complicated doesn’t automatically mean it is better. People
don’t want to be cared for in the same way as dogs. But why, surely it’s good
to be loved, cherished and beneficently cared for? People don’t want to be
cared for in the same way as pets because they value being recognised as
persons which requires recognising them as the kind of creatures who can decide
their own future. It follows if we care about people as persons we must care
about what they care about and this requires caring about them in an empathic
way.
Even
if the above is accepted an objector might argue that if we care about someone empathically
that whilst we must always care about what he cares about, in some situations
we should give priority to acting beneficently. This argument supposes a
particular concept of beneficence. This concept holds that to act beneficently
is to act in someone’s best interests. It also holds that to act beneficently
towards someone doesn’t always means acting in what he perceives to be in his
best interests. This means we must act in accordance with some accepted
standard, perhaps a standard that most reasonable people would accept. But if
we act beneficently in this way who are we acting beneficently towards? We are
certainly acting beneficently to human beings but towards persons? We are
acting as if someone can be a part time person. It might be objected that there
can’t be such a thing as part time person. I find this objection unconvincing.
Children can make some decisions for themselves whilst their parents make
others in their best interests. Children might be regarded as part time
persons. Nonetheless I would suggest that most adults don’t want to be part
time persons being a person is central to them. Perhaps this is one reason why
children want to grow up. Being a person is central to most people’s interests.
Can we be said to be acting truly beneficently towards someone if we are
prepared to ignore what he perceives to be central to his interests? I would
suggest we can’t. If we accept the above, it follows that acting truly beneficently
requires acting in accordance with someone’s perceived best interests and not
what we perceive to be in his best interests. It further follows if we act in a
way that serves someone’s best interests, as we see them, that we are acting in
a caring way, however our caring even if well intentioned is an incomplete form
of caring.
At this point a further objection might be raised. It might be suggested that I’m presenting a misleading view of substantive autonomy. A substantive account of autonomy might be better defined as an account that places some constraints on what an autonomous person can choose, even when his choices don’t harm others, in some limited circumstances but in all other circumstances we should respect his choices. My objector might agree that in the past a basic account of autonomy was sufficient to protect our freedoms. He might now suggest that technological progress and modern medicine mean we have a need for a more sophisticated account of autonomy and that a substantive account satisfies this need. I have questioned above whether any substantive account of autonomy is actually an account of autonomy. I would suggest that any such proposed account is in reality an account of how to balance respect and caring about someone. How to balance respecting autonomy and acting beneficently. My objector might suggest that it is perfectly legitimate to balance these two. In response I would argue that whilst someone might well have a legitimate aim of respecting autonomy and acting beneficently when these two values don’t clash that this clash. A clash of these values depends on a particular account of beneficence. To act beneficently according to this account is to act in someone’s best interests and this doesn’t always means acting in what he perceives to be in his best interests. I have argued above that acting in this way is a deficient form of beneficence and is an incomplete form.
I
have argued that we should reject a substantive account of autonomy for two main
reasons. Firstly, if we adopt a substantive account of autonomy this account
makes itself redundant. Secondly, if we adopt such an account we are not acting
in a truly beneficent or caring way. Accepting the above means we must always accept
someone’s basic autonomous decisions. It also means we cannot ignore such
decisions or coerce someone into changing such a decision. Accepting the above
also means we must sometimes accept bad decisions. Autonomous decisions needn’t
be good decisions. In such cases we should attempt to persuade the decision
maker to change his decision when it is unwise, however if our persuasion fails
we must be prepared to accept the decision.
I
now want to consider what’s wrong with slavery. It might be argued that the
wrongness of slavery is self-evident. Slaves are abused and cruelly treated.
However, R M Hare (4) used a thought experiment to show this need not always
apply. He imagined an island called Juba which was ruled by a benevolent elite
for the good of all with no abuse or cruel punishments. He also imagined an
island called Camaica on which everyone was free but all lived in abject
poverty. He speculated that some free citizens of Camaica might prefer to be
slaves on Juba. If we accept such a situation is possible, even if unlikely,
and we believe slavery is wrong what reasons can we advance for this wrongness.
What is wrong is that the slaves on Juba are not regarded as the kind of creatures
who can determine their own future and this harms them because as I have argued
above for any person the ability to determine his own future is central to his
interests. However, I will now argue that the concept of autonomy violated is
our basic concept of autonomy. Is it conceivable that the substantive autonomy
of the slaves on Juba could be respected? A
substantive account of autonomy might allow a slave’s decisions to be accepted
as autonomous ones and respected provided they are in his best interests and
any decision a slave makes which aren’t in his best interests aren’t regarded
as autonomous ones. If we accept a
substantive account of autonomy, then the autonomy of the slaves on Juba would
be respected. The slaves on Juba would be treated as children or part
time persons. Wasn’t colonialism a bit like this? Beneficent colonialism was a
bit like Hare’s imaginary Juba and treated the people colonised as children or
only part time persons.
Let
us now explore the wrongness of rape using a thought experiment similar to that
of Hare. Let us consider a gentle rapist and a compliant victim. The physical
harms caused by such a gentle rape are minimal nonetheless the crime doesn’t
seem to be a minor one to us. What reasons can be advanced for the seriousness
of a psychically gentle rape? It might be pointed out that the harm lies not
the violence inflicted but the threat of violence, the violation of bodily
integrity or both of these harms. I accept these points. Let us consider the
violation of bodily integrity first. The simple fact that the victim’s body was
penetrated is irrelevant, this could occur during consensual intercourse. What
matters was that her body was penetrated against her will and this involves
failing to respect her autonomy. Let us now consider the threat of physical
harm causing psychological. Let us assume the victim is aware that she will not
be harmed provided she complies. She complies and is raped. She isn’t
psychically harmed and because she complied moreover she had no reason to fear
psychical harm so any psychological harm is not due to fear of being
psychically harmed. In spite of this I would argue psychological harm occurs.
It occurs because she isn’t seen as the kind of creature who has a right to
decide what to do with her own body, she isn’t considered as a person, her
basic autonomy isn’t respected.
If
we accept a non-substantive or basic account of autonomy as the only meaningful
account of autonomy what implications does this have for the doctrine of
informed consent? Is the doctrine of informed consent based on respect for
autonomy? If the doctrine of informed consent is based on a substantive account
of autonomy, then I would suggest the doctrine isn’t actually based on
respecting autonomy for the reasons given above. In this situation the doctrine
of informed consent is concerned with balancing acting beneficently and
respecting autonomy. The concern is to stop people making bad decisions rather
than respecting autonomous ones. This balancing act assumes beneficent care
means acting in someone’s best interests as seen from a particular vantage
point, perhaps what most reasonable people would consider to be in someone’s
best interests. I have argued above such a concept of acting beneficently is an
incomplete concept and that true beneficence requires always accepting basic
autonomous decisions. Autonomous decisions don’t have to be good decisions. However
autonomous decisions are not made randomly or based on mere whims. Autonomous
decisions are based on what we care about, based on what matters to them.
Accepting
the above has important implications and I will now briefly examine three of these.
We might divorce the doctrine of informed consent from respecting autonomy and
simply say that the doctrine is concerned with furthering patients’ best. This
would be an honest approach. However, if we do so when we ask patients for
their consent are we really asking for consent or acquiescence? Alternatively,
we might accept that the doctrine of informed consent is based on respect for
basic autonomy. If we do so it seems to me that a patient can make an
autonomous decision simply to trust his doctor’s advice, after all we trust
lawyers, accountants and other professionals all the time. It also seems that
the information needed to make a basic autonomous decision is less than that
currently supplied when taking informed consent. This might have more to do
with a fear of litigation rather than a misguided concept of autonomy, see montgomery and the information needed for informed
consent . The information required for informed
consent should be patient driven and be determined by how much information he needs
and wants to make an autonomous decision. Secondly democracy depends on voters’
ability to make an autonomous decision. If we accept a basic concept of
autonomy, then perhaps the voting aged should be lowered. Perhaps it should be
lowered to the age needed to give sexual consent. Lastly the United Nations
convention on the rights of persons with disabilities want more people with
cognitive and psychosocial disabilities to make their own decisions, see United
Nations . Let us accept that an autonomous person has the right to
make his own decisions. It follows that how many people with cognitive and
psychosocial disabilities should be able to make these decisions depends on the
concept of autonomy employed. If as I have suggested a basic concept is
employed then more disabled people should be able to make their own decisions
as an autonomous decision is not the same as a good decision. The emphasis
should be on helping such people make good decisions rather than making good
decisions on their behalf.
- John Stuart Mill, 1974, On Liberty, Penguin, page 69
- Christine Korsgaard, 2009, Self-Constitution, Oxford University Press, page 1
- Harry Frankfurt, 1999, Necessity, Volition, and Love. Cambridge, page 114
- R. M. Hare, 1978, What is Wrong with Slavery, Philosophy and Public Affairs 8.
- Matthew Burch, 2017, Autonomy, Respect and the Rights of Persons with Disabilities in Crisis, Journal of Applied Philosophy, Vol 34(3)
