Locking Down the Elderly

Julian Savulescu and James Cameron argue that a policy which locked down the elderly whilst allowing greater freedom to younger people during the covid-19 pandemic wouldn’t be ageist, see practical ethics . The purpose of such a policy would be to protect health services from being overwhelmed. They further argue if such a policy isn’t ageist that it isn’t wrong. In this posting I will accept their argument but suggest that an alternative policy would be preferable. Before proceeding I must make it clear that I am over seventy and one of the elderly however I hope this doesn’t affect the validity of my argument. In the rest of this posting I will use the term ‘older persons’ rather than elderly as this better reflects that the elderly remain persons.

Before making my argument I will briefly outline that of Savulescu and Cameron. They base their argument on Aristotle’s principle of equality. This requires that we treat like cases alike, unless there is a morally relevant difference. They use two examples to illustrate the principle. Firstly if men were allowed to vote and women weren’t this would be sexist and wrong because differences in sex don’t make any difference to the capacity to vote. Secondly government investment in screening women for breast cancer whilst not doing the same for men who sometimes also develop breast cancer isn’t sexist or wrong because men are far less likely to develop this cancer. Let us turn to Savulescu and Cameron’s argument that it wouldn’t be ageist to lockdown older persons whilst allowing younger people greater freedom. They point out that because the cost of the lockdown is massive it is desirable to lift the lockdown. Unfortunately lifting the lockdown might result in health services being overwhelmed. They further point that older persons are much more likely to require health services due to covid-19 than younger ones. They proceed to argue that because that older persons are much more likely to require health care that it wouldn’t be ageist or wrong to require older persons to remain lockdown whilst lifting the lockdown for others due to Aristotle’s principle of equality. When considering the need for health services due to covid-19 outbreak there is a significant difference between older persons and others. It follows that it wouldn’t be ageist to follow a policy which discriminates against older persons in this way.

Let us accept that the above is a perfectly good argument. However it would appear that BAME people are dying at twice the rate of others in the UK. If we accept Savulescu and Cameron’s argument about lockdown for the elderly then the same argument could be applied to BAME people. If it isn’t ageist to lockdown older persons then it shouldn’t be racist to lockdown BAME people. Most would be uneasy about accepting such a conclusion. Let us now consider a different policy which achieves the same ends and which might alleviate our unease. Let us assume that older persons are warned prior the lockdown being lifted, that if this leads to an increase in covid-19 cases which threaten to overwhelm the health services, that they might receive a lower standard of care compared to others. This lower standard is justified because of the disproportionate burden they place on these services. This policy means that older persons might be denied places in ICU and just receive palliative care. Older persons would face a choice of whether to self-isolate or not in order to protect themselves. Let us further assume that the lockdown is lifted and this leads to an increase in covid-19 cases which threaten to overwhelm the health services and as a result older persons start receiving a lower standard of care. Should this policy be regarded as ageist? Let us consider Aristotle’s principle of equality in this scenario. Clearly older persons are treated differently to others but are there any reasons which might justify this difference? I would suggest that there are two reasons which might justify treating older people differently. Firstly older persons are much less likely to survive treatment in ICU. Secondly if treatment in ICU has to be rationed then saving a younger patients at the expense of the elderly means saving patients who will usually live longer and can be justified by utilitarian principles. It would appear that if we accept Aristotle’s principle of equality then a policy which discriminates against older persons in this way wouldn’t be ageist.

I’m self-isolating and believe it is sensible for most older persons to remain in lockdown even if the lockdown were to be partially lifted. I have outlined two policies to protect our health services from becoming overwhelmed in both of which it wouldn’t be ageist to discriminate against older persons. Let us assume that each of these policies would be equally effective in preventing the health from being overwhelmed. Which of these policies should we choose if we accept that it isn’t a question of whether to discriminate but rather when to discriminate.

Let us accept that we have good reasons why we should adopt the first policy as proposed by Savulescu and Cameron. It might be argued that following such policy would protect older persons better than the second. It might be pointed out that if the second policy was adopted that older persons would have to protect themselves. In response it might be pointed out if the first policy is introduced that older persons would still have to protect themselves by remaining compliant. Nonetheless let us accept that we have good reason to adopt the first policy. However it is important to note that the reason to prefer the first policy over the second has nothing to do with protecting our health services from being overwhelmed, both policies do this adequately, the reason for preferring the first policy is to do with caring for older persons. If we choose the first policy then we are also acting beneficently.

Do we have any reasons to choose the second policy instead?  I would suggest that we have two. Firstly adopting the second policy might be more effective as it might be difficult to ensure that older persons remained in long term lockdown under the first policy. I won’t consider this reason further here. Secondly it might be argued that preferring the second policy protects autonomy better. Adopting the first policy serves the interests of all by protecting the health services but it doesn’t respect the autonomy of older individuals. It might then be argued that if the second policy adequately protects health services and respects autonomy that we have reason to prefer this policy. Two objections might be raised to the above argument. Firstly it might be objected that the first policy does respect autonomy. Secondly it might be objected that in times of extreme crisis such as this we should give preference to acting beneficently over respecting autonomy. I will now consider both objections.

What it means to respect autonomy depends on the concept of autonomy used. It might be suggested that an autonomous decision is one that is rationally made to concur with the agent’s best interests and is freely made. If we accept a substantive account of autonomy then these best interests include generally accepted interests such as safety and good health. If we accept a substantive account of autonomy then it might be argued that adopting the first policy is compatible with respecting the autonomy of older persons. Older people, if given the choice, would make an autonomous decision to remain in lockdown because it is in their best interests to stay safe and protect their health. I myself would make such a choice. However let us consider an elderly widow who lives alone and who is suffering from terminal cancer. Let us assume that she is still able to visit her family. If the first policy was adopted she would have to remain in lockdown whilst the rest of her family were free to socialise. I would suggest that if such a person could make an autonomous decision whether to remain in lockdown or not she would choose to socialise with her family. When she considers her best interests she might prioritise family life over staying safely in lockdown. It follows that in this case adopting the first policy wouldn’t respect her autonomy. It might be objected that I have used an extreme example and that we should still prefer the first policy.  I am prepared to accept that I have used an extreme example to illustrate my point but I still want to argue that if we prefer the first policy that we fail to respect the autonomy of older persons. Older persons in general have less future time to look forward to than younger people and many might make an autonomous decision, if they were able to do so, to prioritise family life over staying safe.

Let us accept that if we prefer the first policy then we must be prepared to accept either that acting beneficently is more important than respecting autonomy or that we can respect autonomy whilst acting beneficently. If we accept the second option then we must also accept a substantive account of autonomy. I have argued elsewhere that if we accept a substantive account of autonomy that autonomous decisions must be good decisions, see wooler.scottus . An autonomous decision cannot be a bad decision, it must concur with what is generally accepted to be in the maker’s best interests. However if autonomous decisions must be good decisions then the entire idea of autonomous decision making becomes redundant. We just need to consider good decisions. It follows that if we accept that autonomy is to remain a meaningful concept that we must be prepared to accept a content neutral account. It further follows that if we don’t accept that acting beneficently should be given priority over respecting autonomy that we should prefer the second policy.

However it might be argued that in times like these that acting beneficently is more important than respecting autonomy. Two objections might be raised to the above. Firstly if we prefer the first policy are we really acting beneficently towards older persons? An older person might well believe that leading a social life is in her best interests rather than remaining safe for her last few years. If we disagree we might be accused of epistemic arrogance. Secondly if we give precedence to acting beneficently we are taking acting beneficently to mean ‘caring for’ rather than ‘caring about’. People don’t want to be ‘cared for’ in much the same way as pets are they want to be ‘cared about’ as persons and this means taking their interests into account. It follows if we want to act truly beneficently that we should prefer the second policy.

The Doctrine of Informed Consent and Respect for Autonomy

In this posting I want to examine the relationship, if any, between the doctrine of informed consent and respect for autonomy. In doing so I will try to answer three important questions. Firstly is the doctrine of informed consent based on respecting autonomy or is it a sui generis doctrine? The fact we talk about a doctrine of informed consent seems to suggest the latter. Secondly if informed consent isn’t based on respecting autonomy should it be so based? Lastly if informed consent is based on respecting autonomy what type autonomy should that be?

Is informed consent based on respecting patient autonomy? According to Charles Foster the doctrine of informed consent is in a mess.

“Informed consent, in practice, is a bad joke. It’s a notion created by lawyers, and like many such notions it bears little relationship to the concerns that real humans have when they’re left to themselves, but it creates many artificial, lucrative, and expensive concerns.” Practical Ethics

Let us accept that the principles underlying informed consent are unclear. Let us try to start understanding these underlying principles by examining the process of informed consent in practice. When taking informed consent a patient’s doctors propose some form of treatment and provide the patient with the information he needs in order to make a good decision. The patient then agrees or refuses to agree to this treatment. What is the purpose of this process? The purpose of the agreement part of this process seems clear. The agreement part prevents the patient being treated against his will and his doctors from being accused of assault. The purpose of the information part is different. The purpose of this part is to enable patients to make good decisions. What exactly do we mean by a good decision? A decision which is in the patient’s best interests or an autonomous decision? In a medical setting a decision which is in a patient’s best interests is one which minimises harm to the patient,  maintains or improves his physiological health. The amputation of a patient’s gangrenous leg would be an example of acting in a patient’s best interests by minimising harm. The provision of drugs to control a patient’s blood pressure would be an example of acting in a patient’s best interests by maintaining his physical health. A kidney transplant would be an example of improving a patient’s health. Autonomy is concerned with self-government and very roughly speaking an autonomous decision is one by which someone governs himself. However self-government is simply governing oneself and need not always be good government. We can govern ourselves badly. Let us assume that a patient simply wants to accept his doctors’ judgement about his treatment and doesn’t want to receive any additional information. Intuitively such a decision can be seen as a decision by which he governs himself and as a result is an autonomous decision for after all we can simply choose to follow our lawyer’s advice and most would regard such a decision as autonomous. However under The General Medical Council’s proposed guidelines such a decision might not be seen as a valid informed consent decision.

“If, after discussion, a patient insists that they don’t want even this basic information, you must explain the potential consequences of them not having it. This might include being unable to proceed if you are not confident that their consent would be valid, or if you are not confident that the proposed course of action would be beneficial to the patient overall.” (1)

In the light of the above it would appear that The General Medical Council’s guidelines are not really based on respecting autonomy and the purpose of providing information when taking informed consent is to enable patients make decisions which are in their best interests.

It might be objected that I have only briefly sketched a certain account of autonomy and that a different account might mean that the doctrine of informed consent could be based on respect for autonomy. After all in my brief account the patient in my example above who fully trusted his doctors to make a decision on his behalf might wake up to unexpectedly find himself with only one leg. It might be suggested such a decision isn’t an autonomous one and that we should adopt a more substantive account. For the sake of argument let us assume an autonomous decision must be one that concurs with some generally accepted set of norms. If these norms are to be generally accepted then they must concern what is good for people. Autonomous decisions become linked to good decisions. An autonomous decision must be a good decision and a bad decision cannot be an autonomous one. I now want to argue against accepting such a substantive account of autonomy. If an autonomous decision must be a good decision because it 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. Using a substantive account of autonomy an autonomous decision must of necessity be a good decision according to some accepted norms whilst on a content neutral account of autonomy an autonomous decision can be a bad decision. Of course it is preferable that an autonomous decision, using a content neutral account of autonomy, is a good decision which benefits the decision maker but the purpose of respecting autonomy remains simply to respect the decision maker as a person and the actual decision doesn’t of necessity need to be a good one. If we accept the above then we have two options. Firstly we could abandon the pretence that underlying the doctrine of informed consent is respect for autonomy or secondly we could accept that underlying the doctrine of informed consent is respect for a content neutral or primitive account of autonomy and modify the doctrine accordingly.

If we accept the above then there is not only a difference in complexity between substantive and primitive accounts of autonomy but more importantly these different accounts have a different focus. A substantive account focusses on respecting good decisions, a primitive account focusses respecting persons by simply accepting their decisions. Adopting a primitive account requires adopting a certain degree of humility. Let us accept that if the concept of autonomy is to remain a relevant one that it must be a primitive or content neutral concept based on respecting persons. Such a concept might be classed as a Millian concept. In the rest of this posting ‘autonomy’ will refer to such a concept. Let us also accept the first of the above options that the doctrine of informed consent is a doctrine in its own right and isn’t based on respect for autonomy. The informed consent process starts with a patient’s doctors proposing a course of treatment which they believe to be in his best interests, the patient then consents or refuses to consent to the proposed treatment. I argued above that the purpose of informed consent is to get a patient to consent to treatment which his doctors believe to be in his best interests. In almost all cases the patient simply consents and no problems arise. What is interesting are cases in which the patient refuses to consent. In these cases according to the doctrine of informed consent a patient’s doctors must be sure, or take steps to ensure, that the patient knows the consequences of his actions. However let us assume that the patient maintains his refusal of consent. By what standards is his competence to refuse treatment measured by and how is it assessed? If someone takes a driving test his competence to drive is based on his actual driving. This is not true when assessing someone’s ability to give informed consent. Someone’s competence to give informed consent isn’t based on his actual decisions. His decision might of course trigger a competence assessment but his competence isn’t dependent on his actual decision. Someone’s competence to give informed consent is based on his ability to make good decisions based on his best interests. I would suggest that someone who has the ability to make good decisions based on his best interests is self-governing, is autonomous.

As mentioned above the purpose of a driving test is to measure someone’s competence to drive and the criteria by which his competence is measured is by his actual driving. The same isn’t true of informed consent. I have argued above that the purpose of informed consent is to enable patients to make good decisions. I have further argued above that the way in which a patient’s competence to make good decisions is assessed is by his ability to make autonomous decisions. Such a mismatch creates problems and perhaps is one of the reasons why the doctrine of informed consent is in a mess. Two solutions might be suggested to remedy this mismatch. First the purpose of informed consent should be to enable a patient to make a good decision in particular circumstances and the patient’s competence should be assessed by his ability to make a good decision in these circumstances. Secondly the purpose of informed consent is to enable a patient to make an autonomous decisions and his competence to do so should be assessed by his ability to make an autonomous decision.

Let us consider the first of these options. Let us accept that a good decision is one that is in the decision maker’s best interests and that a decision is a competent one only if the decision is in the decision maker’s best interests. Clearly if someone makes a decision to do something which he believes isn’t in his best interests then he isn’t making a good decision. If a patient’s competence depends on him making a good decision then he is incompetent. Perhaps he is paralysed by fear. However in practice most people make decisions which they believe to be in their best interests. Moreover in a medical setting there is usually agreement between the patient and his doctors about what these best interests are. Unfortunately in a few cases in which there might be disagreement about what is in a patient’s best interests. Let us accept that a patient who makes a decision which he believes to be in his best interests, but which is generally believed not to be in his medical interests by his doctors, is making an incompetent decision. In practice if a child or cognitively challenged adult makes a decision which others believe isn’t in his best interests his competence might be questioned and he might be treated against his will. Unfortunately if a competent decision must be a good decision then the same considerations would seem to apply to all patients. Accepting the above would mean that if any patient makes a decision which is generally regarded as not being his best interests then his decision is an incompetent one. In these circumstances the patient’s doctors might be accused of paternalism or even epistemic arrogance. Fortunately in most cases a patient’s medical best interests and what the patient believes are his overall best interests concur. However this isn’t true in all cases. In cases in which these interests don’t concur do we insist that a competent decision is based on a patient’s best medical interests or what he believes to be in his overall best interests? Practical considerations and the need to avoid the charge of paternalism suggest that we should choose the second option. However if we accept that a patient is making a competent decision when it concurs with what he believes are in his overall best interests we are back to assessing a patient’s competence to make a good decision by assessing his ability to make an autonomous one and the above mismatch remains unresolved.

The above difficulties suggest that we should choose the second option. The purpose of informed consent should be to enable patients to make autonomous decisions about their treatment and that any competence assessment should be based on their ability to make autonomous decisions. This provides an answer to the second of my three initial questions. Informed consent should be based on respect for patient autonomy. Moreover if a substantive account of autonomy makes itself redundant as I have argued above the type of autonomy underlying informed consent must be a primitive or Milliian account. This answers the third of my three initial questions. Accepting this option has consequences for the amount of information which needs to be supplied to patients when taking informed consent. In the past under the doctrine of informed consent a patient’s doctors determined what risks the patient should be made aware of. However the Montgomery ruling Montgomery ruling stated that a patient’s doctors must ensure that the patient is aware of any and all the risks involved. If patients are to make informed consent decisions based on respect for autonomy they don’t always need to be aware of any and all the risks and the Montgomery ruling seems to suggest that informed consent shouldn’t be based on respect for a primitive account of autonomy. However if we accept that if an account of autonomy is to remain a meaningful account that it must be a primitive account then if informed consent is based on respect for autonomy  it must be based on a primitive account. Accepting the above means that a patient’s doctors should have a dialogue with him about any suggested medical procedure. How this dialogue proceeds shouldn’t be preordained by some doctrine but driven by the patient’s needs. In most cases this will include informing him about any major risks and life changes he faces. However some patients might need less or more information in order to make an autonomous decision. As mentioned above an autonomous agent can make an autonomous decision to trust the advice of his lawyer or financial advisor. If someone is non-autonomous someone else might be given power of attorney to act on his behalf. Are doctors any less trustworthy than lawyers or financial advisors? It would seem to me they aren’t. Does then the context in which informed consent takes place differ from other contexts such as the law and finance in respect of an agent’s ability to make autonomous decisions? Provided the patient isn’t incapacitated by fear it isn’t. It follows if informed consent is based on respect for autonomy that a patient should be able to make a competent decision simply to take his doctors’ advice. Other patients might need more information than is usually supplied in order to make an autonomous consent decision. Doctors should make it clear that they are willing to supply more information when this is requested. For instance it might matter greatly to a Jehovah’s witness whether there would be any possibility of a blood transfusion however remote this possibility might be.

It might be objected that I have already introduced an example which shows that it would be absurd to base the doctrine of informed consent on a non-substantive or Millian account of autonomy. Let us agree that if we accept such an account that a patient can make a competent decision simply to trust his doctor. Let us recall the patient with the gangrenous leg. Let us assume that this patient simply wants to trust his doctor and refuses to listen to any information provided. He wakes up and unexpectedly finds he has only one leg. Such a scenario seems absurd. Perhaps then the basis of informed consent should be a substantive account or the doctrine of informed consent should be a self-contained doctrine. Let us assume the patient still wants to simply trust his doctors and refuses to listen to any information concerning his procedure. Should he should be forced to listen to brief details connected to his proposed treatment? Do doctors really want to force someone to listen? Is it possible to force someone to listen and digest information? Should he be left to die? In this situation it seems more likely that the patient would be judged as incompetent. He would then be treated in accordance with his best interests and his leg removed. He wakes up with only one leg. In this case adopting a substantive account of autonomy or considering the doctrine of informed consent as a sui generis doctrine changes nothing. It follows that whilst adopting a non-substantive might lead to some highly undesirable consequences in a few rare cases that it doesn’t lead absurd ones.

1. Supporting patient choices about health and care: Draft Guidance for consultation, GMC, 2019, [33]-[35]

Lying and Autonomy

  

We live in a world surrounded by fake news and lies. According to Terry Pratchett in the Truth “A lie can run round the world before the truth has got its boots on.” However even if lies sometimes spread more easily than the truth, perhaps in part because they are more palatable and we want to believe them, in the long term the truth matters because the truth has persistence which lies don’t. Perhaps the dwindling number of climate change deniers supports the above. Are there any circumstances in which lying is beneficial? Stephen Rainey writing in practicalethics  suggests that some lies “can also be a kindness, when the truth might serve no good”. Let us accept that in most circumstances lying damages both individuals by depriving them of the truth and trust. Nonetheless is Rainey correct when he suggests some lies might be beneficial in some circumstance? For instance might a government be acting beneficently if it lied about the harm done by the coronavirus to prevent panic? The fact that lying hasn’t been eliminated from human culture over time suggests it isn’t harmful in all circumstances. In this posting I want to examine what these circumstances might be. It might be thought that this is merely an interesting rather than important question, however in seeking to answer this question raises a further question about the balance between acting beneficently and respecting autonomy. I will argue that if I lie to someone and even if my lie benefits him that I also fail to respect him by failing to respect his autonomy.

Most people have no problems with defining a lie. The definition I shall adopt here is that of Sam Harris

“To lie is to intentionally mislead others when they expect honest communication.” lying

Lies so defined can explicit when liars intentionally give someone false information. Lies can also be acts of omission when the liar intentionally withholds information others expect him to provide. Perhaps passive aggression can be a form of lying if it involves withholding information. Liars can be practised by individuals, institutions or even governments.

Let us now consider whether it is ever acceptable to lie for beneficent reasons. Because lying is so prevalent our intuitions suggest that it is. Everyday examples seem to confirm our intuitions. For instance the mother who lies to her child by saying she has no money left when her child demands a second ice cream. Someone who lies to his partner about a surprise party. A government which lies to its citizens about the seriousness of some disease outbreak, such as that caused by the coronavirus, in order to prevent mass panic. Nonetheless as Harris points out we need to be extremely cautious about our intuitions. Firstly we must be sure about our motives being really beneficent. Is the mother above really worried about her child becoming obese or simply taking an easy option? Secondly we must be careful not to damage trust. The government above might avert mass panic but in the future its pronouncements on health matters might not be so readily trusted. If a lie cannot be maintained then it is better not to lie at all in order to retain trust. The Chinese government’s attempt to suppress the full extent of the coronavirus outbreak in Wuhan seems to support the above. However let us accept that there are at least some cases in which we might lie for beneficent reasons in which our motives are clear and we don’t damage trust. For instance it would be perfectly acceptable to lie to a stalker carrying a knife about the whereabouts of his ex-girlfriend.

Let us accept that in certain circumstances we can act beneficently by lying, telling white lies. Let us further accept that in some of these circumstances trust isn’t damaged. In such circumstances is Rainey correct when he suggests that lying might be an act of kindness? It certainly seems that because we are behaving beneficently that our actions might be classed as acts of kindness. However I now want to argue even if our lies serve a beneficent purpose and can be classed as acts of kindness that nonetheless it is almost always wrong to lie. Most pet owners are kind to their pets and act beneficently towards them but most people don’t want to be treated in the same way as pets however kindly. They want to be recognised as the sort of creatures who can make their own decisions. To be autonomous. Autonomous people govern themselves and this requires making decisions that matter to them. To make decisions that matters to someone requires information and lying deprives him of some of that information. It follows if we lie to someone we fail to respect his autonomy. Moreover if someone becomes aware of being lied to this lack of respect is a form of rudeness see the philosophy of rudeness.html or form of contempt. It further follows if we believe it is right to respect someone’s autonomy that we shouldn’t lie. It further follows if a government lies to or intentionally misleads the electorate over some issue such as Brexit that it not only deprives the electorate of some of the information needed to make a good decision it also shows a lack of respect for the electorate and perhaps even democracy itself. This lack of respect is similar to the lack of respect many colonialists showed for native people even if their motives were beneficent.

I now want to consider two objections to accepting the above conclusion. My first argument will be based on respecting autonomous persons and my second on respecting autonomous decisions. Firstly it might be objected that we should give precedence to acting beneficently over respecting autonomy and that sometimes lying is the only effective way to act in someone’s best interests. I now want to present two counter arguments against accepting the above. Let us accept that if we need to lie to someone in order to act in what we believe to be their best interests that there must be a clash between what we believe to be in their best interests and what they perceive to be in their best interests. It would appear that we believe we know better than the agent about what is in his best interests or should be in his best interests. In this situation we might be accused of epistemic arrogance. Secondly I would argue if we accept the above objection we don’t really understand what respect means. We can sometimes act beneficently towards someone but part time respect isn’t respect we can’t respect someone only some of the time. We can of course respect someone’s courage but not her wit. However when we respect her as a person we can’t respect her only some of the time. Part time respect just isn’t respect at all. It follows if we lie to someone in order to act beneficently we are not giving precedence to acting beneficently over respecting autonomy we are in reality failing to respect autonomy at all.

Now let us consider respecting autonomous decisions. Let accept to respect an autonomous decision means to accept it. It might be objected that any difference between respecting someone’s autonomous decisions and acting beneficently towards him is largely illusory. This objection depends on accepting a substantive account of autonomy in which autonomous decisions must concur with some accepted norms, autonomous decisions must be good decisions. Accepting such an account means that if we lie to someone, who is making a bad decision, in order to act beneficently towards him we are still respecting his autonomy. Bad decisions just aren’t autonomous decisions. However I am reluctant to accept a substantive account of autonomy. A substantive account has become more prominent recently largely in order to make respecting autonomy concur better with the doctrine of informed consent. Unfortunately as I have argued elsewhere a substantive account of autonomy puts itself out of business, see autonomy and toleration . If autonomous decisions must be good decisions in accord with some accepted norms then we can just consider good decisions and autonomy becomes a redundant concept. Of course if someone is to make an autonomous decision he mustn’t be misled or coerced but it follows that if autonomy is to remain a meaningful concept that we should adopt a primitive or Millian account. It further follows if autonomous decisions needn’t be good decisions that if we lie to a mature adult in order to protect him from a bad decision that we are failing to respect his autonomy. I would suggest accepting the above has implications for apology. Insincere apology is a form of lying. Perhaps in most circumstance apologising without really mean it is a form of white lying. Nonetheless such apologising just compounds any wrong by showing a lack of any real respect to the one lied to.

I have argued that it is always wrong to lie if this means we fail to respect someone’s autonomy even this is done for beneficent reasons. The question now arises is lying ever acceptable? If the mother of a young child who pesters her to buy another ice cream lies then her lie can be justified. The child isn’t autonomous yet and having two ice creams isn’t in her best interests. However caution is needed if we accept a primitive account of autonomy as I suggested above then slightly older children who are capable of making autonomous decisions and lying to them fails to respect their autonomy. Sam Harris uses an extreme example and asks should we lie even if with “Nazis at the door and Anne Frank is in the attic”. Of course we should lie. We should lie to protect Anne Frank and her autonomy. Lying to someone who is infringing someone else’s autonomy is perfectly acceptable, lying to protect autonomy is lying to respect autonomy.

What conclusions can be drawn from the above? Firstly we should never lie if this means failing to respect autonomy even if our lies might be in what we consider to be someone’s best interests. Even white lies are wrong. Secondly if autonomy is to remain a meaningful concept we must always give precedence to respecting autonomy over acting beneficently. Lastly lying to autonomous agents can never be kind.

Assisted Suicide and a Life not Worth Living

Writing in theconversation  Lidia Ripamonti asks if assisted dying became legalised who should decide if a life is worth living. She is assuming that assisted dying would become available to those who have a life not worth living. It might be argued because of dangers of pressure being put on disabled people, the aged and those suffering from mental illness that any such decision should not be solely up to the patient. If not the patient who else can say her life isn’t worth living? Her medical team, her priest or a bioethics committee? Others telling a patient she has a life worth living when she has already decided her life is not worth living seems to be unacceptably arrogant. In philosophy how we frame a question is especially important if we want to draw meaningful conclusions. In this posting I will frame the above question slightly differently. I will then argue that in certain situations we should simply accept the patient’s decision.

If we simply accept the framing of Ripamonti’s question then it is possible to conclude that there may be dangers for the disabled, the aged and the mentally ill if assisted suicide became permissible. I now want to suggest that her question might be better framed Perhaps the question might be framed as follows. If assisted dying is legalised, who gets to decide if someone’s life contains unbearable suffering rather than her experiencing a life which isn’t worth living? It might be argued that if the permissibility of assisted dying is based on unbearable suffering that disabled people and those suffering from mental illness would be better protected because they can live enjoyable worthwhile lives. It might be suggested that others, such as a patient’s medical team, might be able to give an objective answer as to whether the patient is suffering unbearably. Unfortunately it seems impossible to give an objective answer as to whether someone’s suffering is unbearable. One person might find some suffering bearable whilst similar suffering would be unbearable to someone else. Whether suffering is unbearable is a subjective question. Others telling a patient that she doesn’t have unbearable suffering when she has already decided her suffering is unbearable seems to be unacceptably arrogant. It might be suggested that this difficultly might be addressed by replacing unbearable suffering in our amended question by unbearable pain. Perhaps we can measure pain objectively. I’m doubtful whether this might be possible but let us assume for the sake of argument that pain can be measured objectively. However even if this was possible it doesn’t help solve our problem. What matters to some is not the degree of pain alone or how long it will persist but someone’s reaction to it. As with suffering someone might find a pain bearable whilst someone else might find the same degree of pain unbearable. It appears to follow if we don’t want to be accused of arrogance that we cannot replace a ‘life not worth living’ with either ‘unbearable suffering’ or ‘unbearable pain’ in an attempt to reframe Ripamonti’s question.

Ripamonti is concerned that letting the patient solely decide if she has an unbearable life endangers the disabled, the aged and the mentally ill if assisted suicide became available. I accept that Ripamonti is correct provided assisted dying became available across a broad domain. I will now argue that in a restricted domain her concern seem much less pressing. No one is suggesting assisted suicide should be available to anyone who finds her life not worth living. Medicine is concerned with illness not social problems. Let us assume that assisted suicide should only be available to terminally ill patients capable of making a competent decision. If we strictly restrict the domain of patients who could avail themselves of assisted suicide in this way the disabled, the aged and the mentally ill would appear to have little to fear from the legalisation of assisted suicide. Unfortunately this restricted domain appears not to be restricted enough, some terminal diseases may kill someone but can take a long time to do so. For instance Stephen Hawking was diagnosed with motor neurone disease MND in 1963 but lived a highly productive life until his death in 2018. Perhaps then the domain of patients who should be limited to those who are autonomous with a terminal illness and who are expected to live less than six months. Accepting such a domain should protect those suffering from Alzheimers, the disabled, the aged and those suffering from mental illnesses.

However accepting this strict domain causes additional problems which are not easy to resolve. If the domain is restricted to autonomous persons then this restriction protects those suffering from Alzheimers. We don’t, or can’t fully understand what it means to suffer from Alzheimers. But does it always protect children? Consider two patients suffering from terminal cancer both of whom suffer identical pain and find their lives not worth living. Let us assume that assisted suicide becomes permissible but is restricted by the above domain. Let us also assume that the first patient is an adult and as a result is able to end her suffering using assisted suicide. Let next assume that the second patient is a child who because of her suffering also wishes to relieve her suffering by ending her life. Children are not usually considered to be fully autonomous and we have restricted the domain of patients who can avail themselves of assisted suicide to those who are fully autonomous. It might be questioned whether we are really protecting the child. We certainly aren’t protecting her from pain and suffering.

I have argued that autonomous adults with a terminal illness with a prognosis that they will live less than six months and who believe that their life isn’t worth living should have a right to assisted suicide. However because I argued that assisted dying should only be available to autonomous patients creates difficulties and doesn’t protect some patients from pain and suffering. What sort of responses might be made to these difficulties? One response might simply be that I am wrong and that the decision as to whether a patient’s life is not worth living should not be solely up to the patient. Accepting this response would mean Ripamonti’s question becomes pertinent again, who should decide. However I would be reluctant to accept this response because of the reason given above. If someone who is expected to live less than six months believes her life isn’t worth living then it might be asked what pertinent reasons could have others advance to say her life is worth living? Of course others might advance other reasons pertinent to the impermissibility of assisted suicide but these reasons are not pertinent as to whether someone’s life is worth living. It would appear that the decision as to whether a patient’s life is not worth should be solely up to the patient. A second response might be to drop the requirement that the terminally ill patient must be autonomous. Of course how a decision is made to request assisted suicide matters. If such a decision needn’t be an autonomous decision should be replaced by a good decision, I have argued elsewhere that autonomous decisions need not always be good decisions wooler.scottus . Let us accept that a good decision is not simply some decisions regarded as a good decision by the decision maker. Others must also be able to regard the decision as a good decision. However if we accept the above the following might occur. The patient might make a decision that her life is not worth living which she believes is a good decision whilst others believe her decision is a bad one and not in her interests. Once again we might question whether the reasons others give for her life being worth living are pertinent. If others cannot give such reasons then there replacing an autonomous decision by a good decision becomes meaningless. I have argued that if assisted suicide became permissible that initially it should only be made available to autonomous adults with a terminal illness and a prognosis that they will live less than six months and who believe that their life isn’t worth living. I have further argued that who decides if a life isn’t worth living is the person living that life.

What can we learn from the above except that applied philosophy is a messy business? Can any practical conclusions be drawn from the above discussion? First I would argue that the discussion shows how a question is framed matters. Secondly a tight restriction on the domain of people who can avail themselves of assisted suicide gives rise to difficult questions. Such a restricted domain would protect the disabled from exploitation whilst enabling those disabled who meet the criteria to avail themselves of assisted suicide. However such a tightly restricted domain would not protect other vulnerable patients from suffering such as children and those suffering from dementia. None the less I would argue that it is better to protect a limited number of people from suffering than none. Perhaps more work might enable us to extend this tightly restricted domain to others but extreme caution would be needed.

Moral Distress and Autonomy

In Ian McEwan’s book 'The Children’s Act' we have a clear example of moral distress. A judge has to make a decision which is in a child’s best interests when these conflict with his parent’s autonomous wishes. This posting will consider moral distress. What do we mean by moral distress? Moral distress was defined by Jameton as a phenomenon in which someone knows the right action to take, but is constrained from taking it. (1) Moral distress is usually considered in a medical setting but can occur in other areas. For instance a soldier might feel moral distress when carrying out an order which she believes to be morally wrong. It is important to clearly differentiate between distress in general and moral distress. For instance a nurse might be distressed because she feels empathy for a patient’s suffering. However her distress isn’t moral distress. It is also important to be clear about difference between distress caused by moral dilemmas and moral distress. For instance someone might feel distressed because she must either lie to a friend or cause her friend to suffer. She doesn’t know the right thing to do and is experiencing a moral dilemma but not moral distress as defined above. A nurse helping to resuscitate a terminally ill patient suffering great pain might become distressed because she feels she is carrying out an action which she believes is wrong, is suffering moral distress. Moral dilemmas are self-imposed. Moral distress is imposed on the sufferer by others. Both moral dilemmas and moral distress can cause moral injury which can be harmful but in this posting I will only be concerned with moral distress.

What sort of others can cause moral distress? I would suggest moral distress can be caused by two sorts of others. Firstly it can be caused by some authority. This might happen when there is a difference between what someone believes is the right thing to do and what some authority with power over her wants her to do. For example a soldier might suffer moral distress when ordered by her superiors to shell a village which she believes contains a large number of civilians. In a healthcare setting if systems are set up to provide good ethical guidance for healthcare workers this form of moral distress might be reduced. Such guidance might be particularly important during health care emergencies such as the covid-19 outbreak. Secondly moral distress can be caused by respecting someone’s autonomy. For instance a nurse who continues to give a competent patient treatment, which she believes is futile and causes suffering, because the patient requests that her treatment continues.

Most work on moral distress focusses on distress caused by authority. In this posting I want to consider moral distress caused by respecting someone’s autonomy. I will argue that sometimes such distress is sometimes inevitable and difficult to reduce. Someone suffering from moral distress believes she is being asked to do something she believes is wrong. This wrong can take two forms. Firstly respecting someone’s autonomy means that she is asked to do something which conflicts with her beliefs. Secondly respecting someone’s autonomy forces someone to do something wrong by preventing her from acting beneficently. It might be suggested that one way of averting moral distress is for the person suffering the distress to opt out from carrying out the action which is causing the distress. However opting out isn’t easy for someone who believes in respecting autonomy. I would suggest that if you care about someone then you must care about what they care about to some degree even when what they care about conflicts with your beliefs. Caring about someone makes opting out of helping an autonomous person achieve her goals difficult. Caring about differs from caring for. I can care for someone whilst ignoring her wishes but this form of caring is caring in much the same way as someone cares for a child or even a dog. Caring about someone means that the cared about person’s autonomous decisions must carry some weight to the carer and cannot be easily dismissed by the carer. I would further suggest that someone cannot feel genuine empathy for someone if she doesn’t care about what the person she feels empathy for cares about.

Let us assume that respecting autonomy matters and that autonomy is a useful. First let us consider someone who is in moral distress because respecting someone’s autonomous decision means she feels she is prevented from acting beneficently. For instance the nurse in the example I have used above. I would suggest that if the nurse accepts that respecting her patient’s autonomy matters that her moral distress is inevitable. It might be objected that my suggestion depends on a particular account of autonomy and that if we adopted a different account her distress could be avoided. I am using a primitive or Millian account of autonomy. My objector might then suggest that if we adopted a substantive account of autonomy which requires that an autonomous decision must be in a patient’s best interests that the conflict between acting beneficently and respecting autonomy would disappear and with it the moral distress. In response to my objector I will now argue that if we accept a substantive account of autonomy that this account becomes redundant. Let us assume that an autonomous decision isn’t simply some decision made with only reference to what the maker cares about but must also concur with some substantive norms. An autonomous decision must be a good decision. However if we accept that an autonomous decision can’t be a bad decision then the whole idea of an autonomous decision isn’t really much use and we can simply replace all autonomous decisions by good decisions. Let us consider a nurse caring for a terminally ill patient who has one treatment option withdrawn, which the patient desires, because it is regarded as a futile option. If the nurse in question believes in a substantive account of autonomy then this option withdrawal against the patient’s wishes means she will feel no moral distress due to a failure to respect patient autonomy; the patient’s wishes weren’t good wishes because the treatment option was futile and hence weren’t autonomous wishes. If we accept a substantive account of autonomy then the idea of an autonomous decision becomes redundant and can be replaced by a good decision. If we accept that autonomy matters we must be prepared to accept that autonomous decisions can be bad decisions. We must be prepared to accept a primitive account of autonomy. Accepting that autonomous decisions can be bad decisions means that respecting autonomy and acting beneficently will sometimes clash causing inevitable moral distress. It might be argued that opting out of acting might combat this moral distress. I would argue that this option isn’t available in a caring setting. In a caring profession caring about what someone believes to be wrong way is better than not caring at all. It follows that respecting autonomy in a caring profession sometimes makes moral distress inevitable.

My objector might accept a primitive account of autonomy but still suggest that moral distress is not inevitable. She might suggest that autonomy is connected to of my “real self” as opposed to my empirical or actual self. She might proceed to suggest that if we did so my ‘real self’ wouldn’t make bad decisions and that respecting autonomy wouldn’t lead to moral distress. This might lead to the position where someone might think it right to ignore an agent’s intuitively autonomous decision because she believes it does not reflect his real self. I would reject my objector’s suggestion for two reasons. Firstly the world is populated by real people rather than idealised people. Secondly if we accept autonomy is only connected to idealised people who don’t make bad decisions then once again the concept of autonomy becomes redundant and can be replaced by good decision making,

Let us now consider cases where respecting someone’s autonomous decision causes moral distress because it conflicts with the distressed person’s beliefs. For instance a nurse’s religious beliefs might mean she believes we must do all we can to maintain life. Let us assume that she is nursing a terminally patient who isn’t in pain and is expected to continue enjoying a reasonable standard of life for some time. Let us also assume that this patient has made a last directive stating that if she goes into cardiac arrest that she isn’t to be resuscitated. The patient goes into cardiac arrest and the nurse suffers from moral distress because she can’t resuscitate her. Our nurse’s distress is caused by respecting her patient’s autonomy expressed in the last directive. I would suggest that in such scenarios respecting autonomy makes moral distress inevitable. Once again an objector might reject my suggestion. She might attempt to do so not by suggesting that we replace a primitive concept of autonomy by a substantive one but by limiting the domain of autonomous decision making. The domain of autonomous decisions is limited to those decisions which don’t clash with certain basic or religious beliefs. In the example used above the nurse might not suffer moral distress due to respecting autonomy because she believes the patient’s decision isn’t really an autonomous decision because it doesn’t belong in the domain of autonomous decisions. She may of course be forced to respect it by authority. Most hospitals have a policy to respect patients’ last directives. However the basic cause of her moral distress remains respecting patient autonomy. There are two arguments against accepting my objector’s suggestion. Firstly it might be argued that restricting the domain of autonomous decision making removes the importance of autonomy and makes it peripheral to our lives. Someone might end up in a situation in which she could autonomously decide to have an ice cream but couldn’t autonomously decide to have sex if she wasn’t married. Autonomy is about self-government and self-government must of necessity include those decisions which are central to our lives. If the nurse above suffers no moral distress due to respecting autonomy by adopting a limited domain of autonomy then her lack of distress is due to her adopting a deficient idea about the domain of autonomy. Secondly I would argue that any such limitation autonomy is really a surreptitious attempt to reintroduce a substantive concept of autonomy. The domain of autonomous decisions is limited because a larger domain would permit some people to make bad decisions. It is now possible to employ the argument used above against substantive accounts of autonomy. If autonomous decisions cannot be bad decisions then the concept becomes redundant. It follows that respecting someone’s autonomous decision inevitably causes moral distress when the decision conflicts with the respecter’s beliefs.

I have argued that the moral distress caused by respecting autonomy is sometimes inevitable and must simply be accepted by us as the price we pay for viewing other people as the sort of creatures who can decide how to live their lives. We may of course try to get someone to change her mind but if we can’t then respecting her as a particular person and not some idealised person means accepting her decisions and sometimes that means accepting moral distress.

1. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall

Autonomy and Toleration

 

In this posting I want to examine the relationship between autonomy and toleration. This examination will highlight the tension between respecting autonomous decisions and autonomous persons. I will argue that the concept of autonomy we adopt affects how tolerant we should be. Toleration will be defined as accepting choices we believe to be wrong and have the power to change, provided that these choices don’t harm others. John Stuart Mill famously argued that “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 was discussing liberty but the liberty to choose can be described as a primitive form of autonomy. Mill believed if we accept the above then we must also accept that “if all mankind minus one, were of one opinion, and only one person were of the contrary opinion, mankind would be no more justified in silencing that one person, than he, if he had the power, would be justified in silencing mankind. (2) It follows that if we equate autonomy with the liberty of Mill that toleration and autonomy are automatically linked and that we should tolerate any behaviour, which we disapprove of and have the power to change, provided that this behaviour doesn’t harm others.

It might be objected that it is overly simplistic to equate autonomy with liberty and that a more nuanced account of autonomy is needed. How then might we better define autonomy? Let us first consider autonomous decision making. Of course the freedom to choose is a necessary condition for autonomous decision making but it might not be a sufficient one. My objector might suggest that the simple freedom to choose is an insufficient condition for two reasons. Firstly she might suggest that for someone’s decision to be an autonomous one that it must accord with certain accepted norms in addition to the norm of not harming others. For instance if someone made decisions about what she should to do today based solely on her horoscope we might question if she was truly self-governing. My objector might then argue that our concept of autonomy must contain a substantive element and that that there is no meaningful content neutral account of autonomy. Secondly she might suggest that for someone’s decision to be autonomous he must accept Kant’s hypothetical imperative and always choose means that are likely to deliver the ends he seeks. For instance we might question whether someone was really self-governing if one of the ends he desired was increased learning and he sought to acquire this increase by prayer. In the light of my objector’s suggestions two arguments might now be advanced as to why autonomy and toleration need not be linked. Firstly if we accept a substantive account of autonomy which includes some accepted norms then we have no reason, based on respecting autonomous decisions, to accept those decisions which don’t concur with those norms and hence be tolerant.  Secondly it might be argued we have no reason based on respect for autonomy to respect, tolerate, those who choose means that are unlikely to achieve the ends they seek.

I have outlined a possible more nuanced definition of autonomous decision making. However we can respect autonomous decisions or autonomous people. Let us now turn our examination to respecting autonomous people. I will suggest that that respecting an autonomous person means accepting all of her decisions including ones that appear to have been made in a non-autonomous manner. My objector might argue that it is possible to respect someone as an autonomous person without respecting all of her decisions. In order to consider this objection I will first consider what sort of person is an autonomous person and how is she connected to autonomous decision making. It might be suggested that an autonomous person is simply one who always make autonomous decisions. If we accept this definition then we should have no problem in accepting all the decisions made by an autonomous person. However if we accept this suggestion it might be argued that it would be much simpler if we only respected autonomous decisions and ignored the concept of an autonomous person altogether. Moreover most people don’t always make decisions which conform to conditions outlined above for autonomous decision making, indeed it might be suggested that they rarely do so. It follows that if we accept the above that we are only going to respect an extremely small set of human beings as autonomous persons. In the light of the above should we simply respect human beings and forget about respecting autonomous people? I would suggest we shouldn’t. A three year old and an adult in the prime of her faculties differ in their capacities and intuitively the idea of self-control, self-government or autonomy seems central to this difference. Perhaps a better way to define an autonomous person would be to define her as a human being who has the capacity to make autonomous decisions. Such a definition would satisfy most adults because they want to be defined as the kind of creatures who can make their own decisions rather than simply being defined as human beings. Such a definition would also be useful because it defines a meaningful subset of human beings in contrast our previous definition which only defined a narrow subset. Lastly such a definition roughly concurs with Mill’s idea that liberty is “meant to apply to human beings in the maturity of their faculties”. If we accept this definition of an autonomous person then what does it mean to respect such a person? I have suggested above that this means accepting all her decisions which don’t harm others. Let us assume that we don’t respect all the decisions of someone who has the capacity to make autonomous decisions. Which of her decisions should we respect, only the one that are autonomous ones? However doing so means respecting an autonomous person is equivalent to respecting autonomous decisions and the concept of an autonomous person seems to do no work. Let us accept that if the concept of an autonomous person is to be a meaningful one that respecting someone as an autonomous person necessarily means accepting all of her decisions. This position seems to concur with that of Mill. It follows that respecting someone as an autonomous person means respecting, or at the very least accepting, her autonomous decisions. Acceptance of the above and the previously outlined definition of toleration means that we will be tolerant automatically. It means accepting choices we believe to be wrong and have the power to change, provided these choices don’t harm others.

It might be objected that it is difficult to ascertain whether someone has the capacity to make autonomous decisions. She might point out that if we respect autonomous persons and this means that we must respect non-autonomous decisions that this respect causes difficulties for the doctrine of informed consent. My objector might proceed to argue that because of this difficulty it would be much better to assess whether some specific decision was an autonomous one rather than whether the person making it had the capacity to make autonomous decisions. For this reason she might suggest that when we respect autonomy we should only respect autonomous decisions. She might point out that adopting her suggestion would mean that it would be easier to act beneficently towards someone who seems to be making a decision which runs counter to his best interests. If we accept that respecting autonomy means respecting autonomous decisions and accept a substantive account of autonomy then respect for autonomy and toleration aren’t automatically linked. There are no reason based on respect for autonomy as to why we should accept the decisions of others which conflict with our accepted norms. In a western democracy if the wearing of the hijab goes against our accepted norms then there is no reason to accept it based on respect for autonomy not to ban it; similarly in an Islamic state if not wearing the hijab goes against the accepted norms then again then there is no reason to accept not wearing it based on respect for autonomy. It follows that there is no reason based on respect for autonomy, as conceived above, as to why we should be tolerant, unless of course one of our accepted norms is to be tolerant.

It would seem if we believe respecting autonomy means respecting autonomous persons then we should be tolerant, if we accept a substantive account of autonomy and believe respecting autonomy means respecting autonomous decisions then we have no reason based on autonomy to be tolerant. I will now present two arguments as to why we shouldn’t accept that respecting autonomy means respecting substantive autonomous decisions. Firstly I would argue if we do so then we might be accused of epistemic arrogance. Let us accept that any autonomous decision must accord with the hypothetical imperative. Let us assume someone makes a decision using this imperative but that we don’t accept her decision as an autonomous one. It follows that our rejection is based on rejecting the beliefs or norms her decision is based upon. Let us also accept that our beliefs and desires help define us as persons. It follows if we don’t respect someone’s decisions that whilst we might be respecting her as a human being in a caring way but that we aren’t respecting her as a person. Autonomy and the concept of a person are of necessity connected. Most people don’t want to be only respected as a human being but as a person. It follows that if we only respect autonomous decisions we erode the concept of a person. Secondly I will argue that if we only accept a substantive account autonomous decisions that the concept of an autonomous decisions also loses its usefulness. If we only respect substantive autonomous decisions we only respect what we regard as good decisions. It follows if we only respect what we regard as good decisions the idea of autonomous making is doing no useful work and becomes redundant. It follows that that if he concept of autonomy is to remain a useful concept that we should reject a substantive account of autonomous decision making.

I have argued that we should reject a substantive account of autonomy. Most applied philosophers seem wedded to a substantive account of autonomy perhaps, this is because of an unconscious desire to justify their discipline for after all if something is a primitive concept then there is less of a need for applied philosophy. If we reject a substantive of autonomous decision making and still believe autonomy remains important then we must accept that respecting autonomy means respecting those people who have the capacity to make autonomous decisions. Respecting those people who perhaps aren’t as we educated as some are and rely on their emotions more than most people do. If we do so we must still be able to define an autonomous decision. Clearly not all decisions are autonomous. For instance random decisions, coerced decisions or decision made under some internal compulsion, such as a patient refusing consent because of fear, aren’t autonomous decisions. I have argued above that we should reject a substantive account of autonomous decision making because it erodes the idea of a particular person and reduces the need for autonomous decisions by equating them with good decisions. It follows that we should adopt a content neutral or primitive account of autonomous decision making. An autonomous decision is one which is freely made by someone which is based on her own beliefs and is instrumentally rational enough to serve those beliefs. Respecting this primitive concept of autonomy entails that we will be naturally tolerant. Respecting autonomy means accepting choices we believe to be wrong and have the power to change provided that these choices don’t harm others. Lastly if we accept that informed consent is based on respect for patient autonomy then adopting a primitive account of autonomy means a larger number of people should be competent to give consent compared to the number if we adopt a substantive account.

1. Mill J S. (1974) On Liberty and Other Essays. Oxford University Press (Oxfords Worlds Classics), introduction.
2. Mill J S, chapter 2

Autonomy and Beneficence

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.

1. John Stuart Mill, 1974, On Liberty, Penguin, page 69
2. Christine Korsgaard, 2009, Self-Constitution, Oxford University Press, page 1
3. Harry Frankfurt, 1999, Necessity, Volition, and Love. Cambridge, page 114
4. R. M. Hare, 1978, What is Wrong with Slavery, Philosophy and Public Affairs 8.
5. Matthew Burch, 2017, Autonomy, Respect and the Rights of Persons with Disabilities in Crisis, Journal of Applied Philosophy, Vol 34(3)