Autonomy

Why Autonomy?

• Autonomy is broadly construed as a patient’s right to make his own decisions about health care

• Central value in most Western approaches to bioethics

– Feminists are ambivalent about autonomy: important but problematic

Sherwin - Outline

• Reviewing the appeal of the autonomy ideal

• Identifying difficulties with the ideal

• Proposing an alternative conception of autonomy

• Why Sherwin’s use of the term “relational” is distinct from that of some other feminists

• Explain why the relational alternative is more successful than the traditional alternative

• Indicate some implications of adopting the relational view of autonomy

– Changes for health care, specifically

Virtues of Autonomy

• Respect for autonomy is a dominant value in North American culture

– It structures our social relations

• Autonomy is especially important in health care settings

– Patients are dependent on others

– Possibility of manipulation, coercion

– Need services, and often have no alternative

-Autonomy vs. Expertise

• E&E: conflict between autonomy and health

• Sherwin: technical expertise means that health care providers often assume that they know what is best for patients

– Privileges technical knowledge over patient’s knowledge (experiential, values)

-Paternalism, again

• Until recently, paternalism was the norm

– Physicians trained to act paternalistically

– Patient trust = “physician knows best”

– But health care decision-making is an act of self-discovery or self-definition, so the patient must be empowered to make those decisions

-Autonomy and Informed Choice

• Respect for autonomy: competent patients have the authority to accept or refuse treatments offered to them by health care providers

• This principle helps to resolve problems that arise when patient and health care provider do not share the same values

-Autonomy and Power

• Power differential in physician-patient relationship:

– Knowledge differential

– Social status

– Members of disadvantaged groups

• Role of governments, other 3^rd party payers (guidelines, funding policies)

Problems with Autonomy

• Overestimates amount of control that patients have over their care:

– Informed choice vs. informed consent

– Problems with implementation of informed consent (time pressures, poor training)

• Often conceived of as outweighing other values, particularly as being in conflict with justice

• Taxation example

• Role of social arrangements

• Reinforces medicine’s “focus on the individual”

• Treatment, not prevention

• Individual, not cultural/social

• Implications for funding of research, for strategies for prevention

Note that Sherwin is not critiquing just health care professions, also not calling for an end to treating individual patients

The Standard View of Autonomy

• Competent (rational) person

• Reasonable choice from available alternatives…

• …On the basis of sufficient relevant information

• Freedom from coercion

“The paradigm offered for informed consent is built on a model of articulate, intelligent patients who are accustomed to making decisions about the course of their lives and who possess the resources necessary to allow them a range of options to choose from.”

Critiquing the Standard View

• Competent (rational) person

• Reasonable choice from available alternatives…

• …On the basis of sufficient relevant information

• Freedom from coercion

Back to E&E

“Autonomy requires that individuals critically assess their own values and preferences”

(second-order values/preferences

Toward an alternative conception of autonomy

“…specific decisions are embedded within a complex set of relations and policies that constrain (or, ideally, promote) an individual’s ability to exercise autonomy with respect to any particular choice.”

– agency vs. autonomy

-The Relational Self

• Little: moral agents @ individuals who are separate and independent from society.

• Relational view of self: acknowledges that the self we become is shaped by social structures (both interpersonal and political). It also views selfhood as an ongoing process.

-Selfhood and Autonomy

• If we are in a relationship (whether interpersonal or political) that minimizes our self-development, we tend to learn to think of ourselves as incapable of making decisions

• If we are in relationships where we are expected to act for the benefit of others (rather than of ourselves), we tend to think of others first when making our choices

• When we “internalize oppression” this way, we are not capable of more than “minimal autonomy” (Meyers)

– Diminished capacity for self-respect and ability to trust ourselves to make decisions

– Note that although autonomy comes in degrees, it’s also reasonable to talk about a cut-off point at which someone is considered to be autonomous

-Why relational autonomy?

• A relational view of autonomy helps us to see the importance of relationships on specific decisions and therefore to better recognize where oppressive relationships (interpersonal or social) have shaped decisions

• How does a relational view of autonomy affect our understanding of issues in healthcare?

– Social influences on medical decisions (e.g. HRT)

– Patient-provider relationships

– Informed consent

– Research ethics