What do we mean by an autonomous decision? Autonomous
decisions are decisions we govern ourselves by. What does autonomy in practice?
Let us consider a substantive account of autonomy. According to such an account
an autonomous decision isn’t simply one the agent freely makes and doesn’t harm
others. Let us label such an account as a primitive account. According to a
substantive account an agent can only make an autonomous decision if he fully
understands any information relevant to his decision and then makes a rational
decision based on his best interests. Moreover the substantive element of this
account means his best interests are not simply his subjective best interests
but must concur with some norms or objective list. If we accept such an account
then it seems likely that most mentally ill people wouldn’t be competent enough
to consent to voluntary euthanasia and as a result shouldn’t be offered the
option. However if we accept a substantive account of autonomy then the
substantive element means autonomous decisions must be good decisions. I now
want to argue against accepting such a substantive account of autonomy. If
autonomous decisions must be a good decisions because they must concur with
some accepted norms then it might be questioned whether such an account of
autonomy is really doing any useful work. A substantive account of autonomy
puts itself out of business because we only need to consider good and bad
decisions. We don’t need to consider autonomous decisions at all. Some
concerned with medical ethics might be happy to accept the above because they
attach great importance to acting beneficently. Do we value autonomy because it
helps us make good decisions? I would suggest we don’t. I would suggest that we
value autonomy because we value persons. We value being the sort of creatures
that can make their own decisions. We don’t respect autonomy because it helps
us make good decisions we respect autonomy because respect persons. Respecting
persons requires that we accept their decisions and this includes bad
decisions. It follows that respect for autonomy means we should accept a non-substantive
account. It might be objected that we can respect someone’s autonomy by
respecting most of her decisions, but not all, and this means we don’t need to
accept a non-substantive account. In response I would point out respect isn’t a
part time concept.
Let us accept that that we should permit voluntary
euthanasia for persons suffering from terminal who are able to give competent
consent. Let us also accept that any autonomous decision using a non-substantive
account of autonomy should be regarded as a competent one. What might a
non-substantive account of autonomy look like? A random or coerced decision
isn’t an autonomous one. An autonomous decision might have no substantive
element but the way it is made matters. Autonomy is connected to persons and a
person, distinct from a human being, is defined by what he cares about. I would
suggest what we care about must have some persistence. (1) It follows that not
all freely made decisions are autonomous ones. I would also suggest what we
care about depends simply on what we will rather that what it would rational
for us to care about, if this wasn’t so we would be returning to a substantive
account of autonomy.
What are the implications of adopting the above
non-substantive account of autonomy for the mentally ill? Let us accept that
mental illnesses differ. For the purpose of this posting I will assume that
they can be split into two main types. Mental illnesses which induce mood
swings and mental illnesses which cause delusional beliefs. I will consider the
effects of both types on someone’s ability to make an autonomous decision.
First let us consider someone whose mental illness means
she experiences large mood swings. Such mood swings mean that she has
difficulty in making persistent decisions, making autonomous decisions. It
follows she has difficulty in making competent decisions. It follows if
someone’s mental illness leads to large mood swings that she shouldn’t be
offered the option of voluntary euthanasia. The same conclusion cannot be so
easily reached if someone’s mental illness leads to delusional beliefs. Her
decisions even if they are based on these beliefs might have persistence,
reflect her will and if so should be regarded as autonomous and hence competent.
At this point it might be objected that it would be absurd to accept as
competent any decision based on a delusional belief. In response I would point
out that this occurs in medical practice now. Consider a Jehovah’s Witness who
needs a blood transfusion without which she will die. She believes that if she
permits the transfusion that she will not be admitted to heaven. Because of
this belief she refuses the blood transfusion. Her decision would be regarded
as a competent one under existing guidelines. However to most people including
me such a belief is a delusional one. It seem that in practice a decision based
on a delusional belief might be regarded as a competent one. Perhaps then if
someone suffering from mental illness makes a persistent decision based on
delusion his decision should be regarded as a competent one. Perhaps also
someone whose mental illness causes delusions might be competent enough to
agree to voluntary euthanasia.
It might be objected that whilst some people have long
standing delusions which help define them as persons such as the Jehovah’s
Witness. My objector might then point that some people suffering from mental
illness might be treated for their mental illness causing them to lose their
delusional beliefs. Their delusional beliefs don’t define them as persons. I
accept my objectors point but might in turn point out for someone suffering
from a terminal illness time is limited and a change in her delusions is
unlikely. Someone with a limited expected life span who suffers from long term
delusions might be partly defined as a person by her delusions. If such a
person has a terminal illness she might well to able to make an autonomous,
competent, decision to accept voluntary euthanasia and should be offered the
option. My objector might raise another objection to the above. She might
suggest that my division of mental illnesses into two main types is flawed. She
might point out depression doesn’t fit easily into either type. Once again I am
prepared to accept her point. If depression can be quickly cured then someone’s
depression doesn’t play a part in defining her as a person. Someone suffering
from short term depression might not be able to make competent decisions and
should not be offered voluntary euthanasia. However some depression is deep
seated and play a part in defining someone as a person. This might be
especially true for someone suffering from a terminal illness with a limited
expected life span. Someone suffering from a terminal illness with deep
depression might well to able to make an autonomous, competent, decision to
accept voluntary euthanasia and should be offered the option.
What conclusions can be drawn from the above? First that
applied philosophy can be a messy business and that mental illness is a broad
concept. It follows not all of those suffering from a terminal disease and mental
illness should have the option of voluntary euthanasia. However those who can make an autonomous
decision should. The above highlights the difficulties legislators, such as
those in Canada, face when drawing up laws covering voluntary euthanasia. Lastly
the concept of autonomy employed should be a non-substantive one.
- Harry Frankfurt, 1988, The Importance of What We Care About, Cambridge University Press, page114.
