The nature of autonomy

The nature of autonomy
In the introduction I suggested that consent is predicated on autonomy. If one considers the role consent plays, which I will discuss in more detail in Chapter 4, the connection with autonomy seems apparent. It has not, however, gone unchallenged and I will address this later in the chapter.1 Starting with the etymological derivation of autonomy, which comes from the Greek and means self-rule, both senses of consent – as a waiver of a right and as a negotiated agreement – depend on the patient’s autonomy, at least in the sense of autonomy as self-determination. Consent raises issues of liberty, power, control and responsibility; all of which are also relevant to the importance of autonomy.2 Because of this connection, it is essential to explore autonomy in some detail. This will allow the attributes of consent to be given more substance, which is a necessary part of determining the moral and legal duties that consent imposes on the healthcare professional. To explicate autonomy and its influence on consent I will explore the nature, value and limits of autonomy. I will then examine the nature of the connection between consent and autonomy.

The nature of autonomy Various senses and conceptions of autonomy have been expounded.3 If there are real differences between these approaches to autonomy then the conception adopted may affect the obligations arising from the patient’s right of consent. Rather than simply assert my own version of autonomy, recognising these competing conceptions makes it necessary to consider the different views. It seems appropriate to begin with the list that Gerald Dworkin constructed in his classic exposition of autonomy, which includes autonomy as liberty or freedom to act; as dignity; as ‘freedom of the will’; as ‘independence’; and as ‘critical reflection’.4 The list may be expanded to include: ‘self-mastery; choosing freely; choosing one’s own moral position and accepting responsibility for one’s choice’;5 ‘self-control’ and ‘self-determination’.6 It is apparent from this list that one of the problems with autonomy is that there are almost as many different conceptions as there are commentators writing on the subject. However, this does not mean that there is no single concept and, rather than simply being alternative concepts of autonomy, the various uses of autonomy reflect an amalgam of the different aspects and senses of autonomy.

Approached in this way, it may be possible, in the context of healthcare, to determine a core concept with a choice of conceptions. The most meaningful conception may then be determined from the value reflected in the core concept and the context of its application. The core concept is revealed by the etymology of the word itself. As noted above, autonomy literally means self-rule and this is the central feature of all the various different conceptions. This central notion depends on the claim that we are free-willed agents capable, at least, of making decisions. I will discuss the problem of determinism later, but for now I will assume that adult human beings ordinarily are capable of self-determination. Where rationality is required then this capacity may vary greatly between individuals. Furthermore, the psychological predisposition to exercise the ability may also vary (see p. 91). However, the capacity for self-determination is a necessary feature of agency, which is crucial to the justification provided by consent. This capacity for self-determination means that, at its core, autonomy is a natural kind concept. However, the different conceptions that have been argued for are, to a greater or lesser extent, social constructs that rely on a mixture of biological and normative claims. The normative claims essentially depend on the type of society, or more specifically to the present discussion, the type of healthcare service that the author is arguing for. A libertarian will construct a different conception of autonomy to the liberal and the liberal view will differ from the communitarian.7 These fundamentally different perspectives on autonomy mean that it is unlikely that the debate will ever be fully resolved in favour of one conception over another. This is not, however, a problem. In fact, the opposite is true since these different approaches provide the basis for the criticism necessary to a vibrant democratic politic.8 The caveat is, of course, that unless we are content with incoherent and inconsistent rules, the law, and indeed professional ethical guidelines, must choose one version over another. This choice will not be fixed for all time, but will be subject to the continuing critique of others with differing views.

Nevertheless, a conception of autonomy should be selected with the preferred choice determined by the type of healthcare system we want. Although there are many different conceptions of autonomy they can be broadly grouped into three categories. The libertarian approach is to see autonomy simply as self-determination. The liberal view requires the inclusion of rationality. The communitarian approach would be to require autonomy to also have substantive moral content. While it is possible to discern these three broad characterisations of autonomy this is not to suggest that they are discrete. In particular the inclusion of a requirement for rationality adds another dimension that it is susceptible to one’s political persuasion and allows for a complex and nuanced approach to autonomy. The different nuances at play allow the conception of autonomy to be seen as existing on a continuum that spans from the extreme libertarian view of autonomy as atomistic, independent self-determination to the communitarian extreme in which the importance of individual autonomy is subjugated to the needs and interests of the community. Between these caricatured approaches lie many more plausible conceptions. In the subsequent discussion I will begin to construct an argument setting out the conception of autonomy that should ground the legal regulation of consent.

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