Autonomy
Often when people are talking about autonomy, they really mean "respect for autonomy"
It's central to Kant, and one of the "four principles" of Beauchamp and Childress (maybe the most important? the "first among equals"?)
Recently, over the last 50 years, theres been a shift to a more "autonomy respecting" approach
It underpins a lot of other ethical issues. You can't talk about consent/truth telling/etc, without bringing up autonomy.
So what do you really specifically mean by autonomy?
What is it's nature? What is it's limitations? When can you override their autonomy?
What is it?
It's about self rule, self govenment, self determination ("autos" = self,"nomos" = rule)
It was originally a political rule, talking about autonomous city states in ancient greek.
It's to be in control of oneself, making (hopefully) rational decisions about yourself.
What does it mean to make decision regarding myself?
Distinctions
There is a difference between the capacity for autonomy, and the ability to act autonomously.
You may have the capacity if you're capable of understanding the information, but lack the ability to act freely (as your liberty is being witheld, as an example, or if information is witheld to you)
There is a difference between autonomy and freedom
Your freedom can be definied in multiple ways, one of them is "you're free, if you can do what you want to do". This is called negative freedom. It's freedom from interference. Your lack of freedom can inhibit exercise of autonomy, but not always.
[So can you not really interfere with someones autonomy, as they lacked autonomy in the first place?] [Is autonomy being treated the same as capacity here?]
An example of temporary loss of autonomy is delirium, or when someones going through in drug withdrawal. Someone going into drug withdrawal rehab, aware they're going to lose autonomy when experiencing this. Do you respect their wishes when they say they want to go throough rehab, or when they're withdrawing and say they want to leave? (This is called a Uylsses contract- talking about odysesseus and the sirens)
Kant, Autonomy, and Rationality
Kant thinks our capacity for autonomy is what seperates us for non rational beings. And it's your capacity for autonomy that allows you to act as an end in yourself.
Autonomy is what you use to attribute people moral worth.
Modernity
Modern ethicists agree with Kant about the fact autonomy is important, but for different reasons.
Kant thinks we're all self governing, when we act according to reason we're acting "autonomously", and when we act according to desire we're acting "heteronomous". The problem with this that it doesn't really take emotions/desires into any positive account. Kant doesn't think people acting according to their desires are acting autonomously.
Is reason alone really sufficient to govern action? Nah, you probably need an additional motivation or desire (besire accounts, belief plus desire)
Our desires are part of our appropriate self, according to value ethics. So ignoring your character is ignoring a big part of autonomy. Denying people autonomy for using their desires doesn't seem right.
And we generally don't use Kant in real life. We respect decisions that seem irrational to us, we respect the persons autonomy.
Modern accounts generally allow a role of desire in autonomy. So it allows "our own authentic desires" to take a place.
They try to reflect on desires, and then accept/reject/rank your desires.
You can talk about first and second order preferences: First order desires are the desires themselves - what are my thoughts? Second order desires are the desires about desires - what do I wish my thoughts are?
An authentic desire, is the desires you've had the opportunity to reflect on, and pick what's most important to you.
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So if you are weak willed, do you lack autonomy? So if you're under influence of drugs/alcohol, are you autonomous?
So there are always going to be complications about whether someone is an autonomous agent.
Principle of Respect For Autonomy
Read Dworkin - Autonomy []
How should we act towards autonomous agents?
A weak principle would tell you you have an obligation or duty not to inerfere with peoples autonomous decisions - don't interfere with people - leave them alone
A strong principle would be we have a "positive duty" to promote autonomy in others. This may just be a prima facie duty, that can be outweighed by other moral considerations.
So why is autonomy ethically important?
Deontological - Kant says autonomy is what defines a person as a moral agent. To violate their autonomy is to fail to respect them as a person.
Instrumentally valuable - Utilitarians say respecting autonomy is a way of maximising happiness. Autonomy is a means to an end.
Intrinsically valuable - Autonomy is a constituent of happiness, not just a means to happiness. "It is desirable that ... individuality should assert itself". This is still a utilitarian view. It's still about maximising happiness. It's just this time it is essential to improving happiness rather than a mean.
With the accounts of instrumental and intrinsic valuable arguments, Autonomy is not a seperate moral principle. Its part of the overarching strategy to improve morality. Kant in his deontological argument has autonomy as a seperate moral theory.
Autonomy in Practice
You can respect autonomy through negative duties (things not to do) and positive duties (things to do). Do these positive duties (keeping confidentiality, helping people to act on autonomous decisions) enhance autonomy really though?
Why might you override autonomy?
- To prevent harm to patient
- To benefit the patient
- To prevent harm to others (quarantine for infectious diseases)
- To benefit others (research, to discover treatments that may help other sufferers)
i + ii are versions of paternalism
Paternalism
Widely regarded as a "bad thing". Is it always though?
Paternalism is the interference with someones autonomy (either by stopping them doing what they want, or witholding/providing different information), through reasons to promote the interests of them.
Paternalistic approaches are ways to protect you from yourself (seatbelts, taxes, etc)
Some of these are accepted by society at large. But why are they so much more contentious in medicine?
John Stuart Mill, in On Liberty, talks about the importance of self protection. He says the only reason to withold someones autonomy, is to prevent harm to others. You cannot do it to prevent them harming themselves. You can argue, but you can't withold their autonomy.
One distinction made about paternalism is "weak" versus "strong" Weak is where the motivation is a beneficent wish to prevent harm from a non-autonomous decision. Strong paternalism is desire to prevent harm from an autonomous decision.
Is weak paternalism paternalism at all? If they have no autonomy, it's not paternalism. So one of the difficulties is deciding what to do depending on how much autonomy they have.