Autonomy: amorphous or just impossible?

By Charles Foster

I have just finished writing a book about dignity in bioethics. Much of it was a defence against the allegation that dignity is hopelessly amorphous; feel-good philosophical window-dressing; the name we give to whatever principle gives us the answer to a bioethical conundrum that we think is right.

This allegation usually comes from the thoroughgoing autonomists – people who think that autonomy is the only principle we need. There aren’t many of them in academic ethics, but there are lots of them in the ranks of the professional guideline drafters, (look, for instance, at the GMC’s guidelines on consenting patients) and so they have an unhealthy influence on the zeitgeist.

The allegation is ironic. The idea of autonomy is hardly less amorphous. To give it any sort of backbone you have to adopt an icy, unattractive, Millian, absolutist version of autonomy. I suspect that the widespread adoption of this account is a consequence not of a reasoned conviction that this version is correct, but of a need, rooted in cognitive dissonance, to maintain faith with the fundamentalist notions that there is a single principle in bioethics, and that that principle must keep us safe from the well-documented evils of paternalism. Autonomy-worship is primarily a reaction against paternalism. Reaction is not a good way to philosophise.

To  say that autonomy means respecting autonomous choice does not save it from all critics of its claims to be coherently normative.  One example: when X considers a potentially life-saving  treatment, whose autonomous choice is the decider? Is it X the father who wants to see his children grow up? X the husband who doesn’t want to be a burden? X the Jehovah’s Witness, fearful of hell?  X the fearful human, fearful of oblivion? Surely it is unusual to meet an X who is so well integrated as to be able to deliver a single, unequivocal answer to the question ‘What do you want?’ I’m not sure I’d like to meet such a person. Human beings (or at least the sort that you’d like to have to dinner) are defined by their contradictions and the exhilarating tensions between them.

But let’s assume that one can say that the definition ‘respecting autonomous choice’ does have a sufficiently substantive meaning to be theoretically useful. Can it in fact be honoured in the real healthcare environment?  No, says an important paper in the Journal of Medical Ethics by Agledahl, Forde and Wifstad. We have fatally failed to distinguish between the notion of autonomy in medical research (where one can have pretty pure, textbook cases of ‘informed consent’), and the same notion in the real world of medical treatment (where one can’t). We talk about a consultation with a surgeon in the same language as we talk about a consultation with the co-ordinator of a clinical trial. That language, which makes perfect sense in the RCT context, is gibberish when the subject turns to the question of the available options for managing your osteoarthritic hip.

Two examples from the paper make the point.

First : The route to a particular procedure rarely involves just one consultation between one clinician and one patient. Clinical practice is a ‘process over time and space in which several participants guide the actions that are taken…’ This, observe Agledahl et al, ‘makes it harder to define who has made the decision, identify who has the moral responsibility and understand what respecting a patient’s right to autonomous choice could mean.’

And second: patient choice is restricted by what is available in a particular healthcare system, and accordingly consultations necessarily direct patients towards the available choices. That’s not paternalism: it’s realism. ‘[C]ouldn’t I speak to [the] surgeons directly?’, asks a hypothetical young man in one of Agledahl et al’s examples. ‘Well….yes’, replies the doctor on call, ‘you could certainly call the hospital and ask for them yourself, but I’m not sure that you will be allowed to speak to them. Or else your family doctor could refer you straight to the district general hospital…[But] it will be quicker if we could examine you first and refer you based on our examination.’

The patient’s choice is being subverted. The respect given to his choice is trimmed because of the necessary organisation and financing of healthcare. One might add that even in a healthcare system unconstrained by any financial or organisational limitations, informed consent is practically impossible.  When a practitioner prescribes paracetamol, she simply cannot summarise all the complications that have been described in the literature, tailoring her assessment of the risk of that complication in the patient. The medical literature is just too vast for doctors to paint the picture for patients in anything other than a very broad, choice-truncating brush.

Agledahl et al conclude: ‘Respecting persons as autonomous persons is far more complex than eliciting choices and acknowledging informed consent….Respecting patients as autonomous persons is an important moral issue in clinical work, but it is misleading to relate this respect to the degree of choosing….[T]here is a danger that the current [autonomy-driven] discourse is creating a gap between medical practice and medical ethics, and that doctors are adapting a language from bioethics that does not properly portray their sense of moral responsibility.’

Quite right. We need urgently to disown the monolithic fundamentalism of pop-ethics, and embrace a truly liberal pluralism that listens respectfully to the voices of many principles. Proper pluralism isn’t incoherence. I’ll be suggesting that the harmonious joinder of all those voices is the sound of dignity.