The place of autonomy in bioethics.

The Place of Autonomy in Bioethics I come not to bury autonomy, but to praise it. Yet my praise is somewhat muted; for autonomy merits only two cheers, not three. Five years ago at the fifteenth anniversary of the founding of The Hastings Center the general theme was "Autonomy - Paternalism - Community." Hearing several sharp criticisms - indeed, virtual rejections of autonomy - I stressed in my oral remarks and later in my published paper that we "need several independent moral principles, such as individual and communal beneficence and respect for personal autonomy." It is "unfortunate and even pernicious," I continued, to suggest that "biomedical ethics is allegedly moving beyond autonomy to community and paternalism," for such an approach would reduce "ethical reflection to a mere mirror of societal concerns at a particular time, when in fact the task for serious ethical reflection is to indicate the importance and relative weight of several moral considerations that should be maintained in some tension or balance."[1] Reaffirming that statement five years later, I want to defend the principle of respect for personal autonomy as one among several important moral principles in biomedical ethics. My defense will proceed by sketching and clarifying some presuppositions and implications of this principle in light of several major criticisms. Many of those criticisms are misplaced, because they are (perhaps deliberately) not directed at the most defensible conceptions of the principle of respect for autonomy. I will contend that an adequate conception of the principle of respect for autonomy can meet the main criticisms levelled by various critics, whether communitarians, narrativists, virtue theorists, traditionalists, or religionists. My main argument focuses on the principle of respect for autonomy as an important moral limit and as limited. As a moral limit, it constrains actions; but it is also limited in scope and in weight, in addition to being complex in its application. Both critics and defenders tend to neglect these senses of limit in their focus on an oversimplified, overextended, overweighted principle of respect for autonomy. Misdirected Criticisms In several ways, the principle of respect for autonomy has been misunderstood and misinterpreted, in part as a result of flawed formulations and defenses by its supporters. Critics have often supposed that they were attacking the concept of autonomy when in fact they were aiming their fire at particular conceptions of autonomy, often the least defensible ones. It has been a mistake to use the term "autonomy" or even the phrase "principle of autonomy" as a shorthand expression for "the principle of respect for autonomy."[2] It is important to correct this mistake because many critics seem to suppose that proponents of this principle have an ideal of personal autonomy and believe that we ought to be autonomous persons and make autonomous choices. However, the ideal of personal autonomy is neither a presupposition nor an implication of the principle of respect for personal autonomy, which obligates us to respect the autonomous choices and actions of others. The ideal of autonomy must be distinguished from the conditions for autonomous choice. It is important for the moral life that people be competent, be informed, and act voluntarily. But they may choose, for example, to yield their first-order decisions (that is, their decisions about the rightness and wrongness of particular modes of conduct). For example, they may yield to their physicians when medical treatment is proposed or to their religious institution in matters of sexual ethics. Abdication of first-order autonomy appears to involve heteronomy, that is, rule by others. However, if a person autonomously chooses to yield first-order decisionmaking to a professional or to a religious institution, that person has exercised what may be called second-order autonomy. …