Autonomy Today, and Autonomy Tomorrow, next Wednesday, and for the Rest of Your Life

We'll continue to chip away at the concept of autonomy next week, but for those of you who walked away with unanswered questions, I recommend John Christman's article on autonomy in the Stanford Encyclopedia of Philosophy--an excellent online resource for all things philosophical.

Here are some of the passages I found especially relevant to our discussion:

Put most simply, to be autonomous is to be one's own person, to be directed by considerations, desires, conditions, and characteristics that are not simply imposed externally upon one, but are part of what can somehow be considered one's authentic self.

...autonomy can be used to refer both to the global condition (autonomous personhood) and as a more local notion (autonomous relative to a particular trait, range of acts, or aspect of one's life). Addicted smokers for example are autonomous persons in a general sense but (for some) helplessly unable to control their behavior regarding this one activity.

In addition, we must keep separate the idea of basic autonomy, the minimal status of being responsible, independent and able to speak for oneself, from ideal autonomy, an achievement that serves as a goal to which we might aspire and according to which a person is maximally authentic and free of manipulative, self-distorting influences.

Christman's notion of an "authentic self" plays a role similar to Ackerman's deliberate life plans, and to Goldman's preferences and value-orderings. Whichever terminology we choose, there seems to be some gray area between externally imposed choices on the one hand, and "authentic," internally motivated choices on the other. How we draw the line between external and internal sources of action is what's at issue between competing accounts of autonomy.

What does it mean for beliefs, desires, and values to be a part of one's "authentic self"? Can we simply choose, as if by fiat, what constitutes our authentic selves, say, by making a New Year's resolution to maintain a healthy diet? Or is who I really am at least partially determined by unreflectively adopted habits, like my habit of eating at McDonald's? Could my authentic self contain both of these at the same time? Does one of them 'outrank' the other?

I'm don't know. But I look forward to discussing the next article with you next week; Emanuel and Emanuel try to individuate four different models of the doctor/patient relationship by correlating them with four different conceptions of autonomy, so maybe they can help us out. Happy reading, and happy blogging.

UPDATE: You might also want to look at Sarah Buss's article on personal autonomy.

Two Kinds of Patient-hood

Pellegrino writes (quoted in Ackerman, pg.74): "The state of being ill is therefore a state of 'wounded humanity,' a person compromised in his fundamental capacity to deal with his vulnerability."

I suspect that there are two ways to understand the notion of "patient-hood" and its relation to patient autonomy. The first way is this: to regard a patient (=a person suffering illness of some serious degree) as being different from a healthy person in some fundamental way. According to this understanding of patient-hood, illness diminishes an essential quality that comprises a human being, namely, autonomy. The second way to understand the concept of patient-hood is to regard a patient as being different from a healthy person in some "merely" temporary aspect, and that a patient is no different from a healthy person except that a patient's life is inhibited by illness.

Example: We would not regard John (who is an average guy) in a drunk state is fundamentally different from John in his normal waking state. Once John becomes sober, he will return to his normal self--so drunkenness is only a temporary alteration, an inhibition that can be lifted. But if John lost a part of his mental capacity (say, to recognize people's faces), perhaps as a result of an accident, it is likely that we regard post-accident John as being somehow fundamentally different from pre-accident John.

Why does distinguishing the two ways to understand patient-hood matter?

The first way of understanding patient-hood supports paternalism. If patient-hood implies a loss in the patient's capacity for autonomy, then it is unclear how the patient's autonomy can be respected in the first place. There is no overarching patient autonomy that physicians must respect; rather, the aim of medical treatment becomes eliminating the factors that inhibit patient's autonomy--that is, curing the illness becomes the overarching aim. Patenralism, thus, can be justified on instances where it would lead to better consequences for the patient.

The second way of understanding patient-hood supports patient autonomy. Since autonomy is something that must be respected in all occasions (perhaps there are exceptions; eg. when autonomy is voluntarily relinquished), and since the second concept of patient-hood regards patients as possessing the capacity of autonomy just as much as healthy people, it should follow that autonomy must be considered as something that is to be respected even if it means that a patient will be worse off in the long run.

Now, I am open to the possibility that in some cases, the nature of an illness is so that the first understanding of patient-hood is more plausible, while there may be cases where the second understanding is better suited. What such a possibility implies, I think, is clear.

Ackerman points out that "no longer is it permissible for a doctor to withhold information from a patient, even on the grounds that it may be harmful." Thus we have informed consent. Arguably, how can a doctor be sure that the patient is indeed informed, and that said patient is making a decision for about his or her health without having been coerced by family, or societal pressure? These are just some of the questions posed in the article "Why Doctors Should Intervene".

It is my belief that besides providing the best care for their patients possible according to AMA practices and standards, doctors must ensure that their position of "authority" is not abused. From my own experiences with family members, and as noted in class and in the article, there are certainly times when patients defer to their physicians to make decisions for them. If a patient chooses to do that and allow the doctor to direct his or her care without formal involvement is a choice that that patient made. At that point, and I believe the doctor has the patient's permission to intervene, but certainly the doctor should continue to inform the patient of his or her options and the course of care the doctor recommends.

Doctors should intervene when patients ask them to, (unless of course there is an emergency and a decision needs to be made quickly; or if the patient cannot speak for themselves for some reason other means should be found to ensure the patient's rights are not violated) it should not be automatically assumed that the doctor should intervene without the request being made by the patient.

Beneficence Today? Give me autonomy.

The central idea of the concept of "autonomy" according to the context of this article is that an able-minded, relatively rational thinking person makes an informed decision concerning his/her health. In the case of forty-nine year old Monica with a form of terminal cancer, the author seems to ask if the medical team should truly allow Monica autonomy in what appears to be a no win situation for her, or if in their definition of compassionate care, the team should step in to make the determination on how Monica would be best off. I agree with the commetary offered by Elger when she notes in her conclusion "in the abscene of written or oral directives, not waking Monica would be an unjustifiable form of hard paternalism."

How can a physician assume total responsibility for how a patient chooses to live (or die)? Is that the role of a physician? If the issue is strictly on providing care, then Monica's team of physicians have done their jobs to the extent that she is as stable as her condition will allow. Because it seems possible to "wake" Monica from her sedative state, even though she may be in pain by doing so, why shouldn't she at least be allowed to have her voice heard? If Monica had no chance of resusitation or the ability to regain conciousness then wouldn't the physicians be required to contact any known next of kin to see if they could speak on behalf of the patient's wishes? It certainly seems unethical and perhaps illegal for a physician to take a patient's life into his/her hands soley on the basis of what he/she believes is right when there is the opportunity to let the patient (or patient's family or friends) make such an important decision. Afterall, that doctor may have just met Monica for the first time when she was admitted into the hospital. Each person is an individual in that we don't all view life and death issues the same way. Why would the physicians even want the burden of assuming that for a complete stranger when the decision is probably twice as difficult when it's made for oneself?

Reserve Materials

Readings for the next few weeks are now on ERes. Just click on "Electronic Reserves & Reserves Pages," and search by course number, course name, department, or instructor. Here is the link:

http://eres.wustl.edu

As always, let me know if you run into any problems.

The Relativity of Values: Health and Life

While reading the first paragraph of the author Alan Goldman's article on Relativity of Values: Health and Life, the questions that came to mind is, how do we know a person is actually acting irrationally or inconsistently when it comes to their own long range preferences? At what point is it ok to have paternalistic interference be justified? Of course, the people who actually know the person really well, (family members and close friends), can tell if something is not in sync with the decisions this person decides to make. But what about this person changing their mind that seems logical to them about how they want their health handled? And what if even close family and friends think this is irrational thinking, when in fact, this is the way the patient wants it? What if this person made statements their whole lives mentioning that no matter what happens to them, they wish to be hooked up to a ventilator and have their life prolonged as much as possible, in hopes of a miracle, and then when the time comes when they are in the hospital, fully aware of what is going on, decide to not be attached to any medical equipment to prolong their life knowing their life is going downhill and the pain they are in, to be let go naturally and let nature run it's course? Would this decision be irrational, or would it be just the patient changing his mind while going through these hardships?

Autonomy, Paternalism, and Medical Models

In medicine and in life there are cases for and against paternalism. I agree with the author Alan Goldman. Nevertheless, adults should be allowed choices. In America, patients have "The Patient's Bill of Rights" that gives patients the rights like privacy and confidentiality, involvement in their treatment, right to refuse, continuity of care, etc. The best judge of a patient's interests can only be the patient themselves, if they are informed -- they know their values and beliefs.

The invoking of paternalism in the example of ignorance when Dick desires to board a New York train but almost boards a Boston train instead certainly warrants coercing in most cases since this is what the subject initially desired. However, did it not deny him the right to possible learn from a mistake? Jane, in contrast, not donning a motocycle helmet, does not warrant paternalism; She should have the right to wear or not to wear a helmet, as an adult -- whether it shortens her life or not, it is her choice. Maybe she wants to "live in the moment." The "minor nuisance" can make a big difference in the thrill and enjoyment of riding a motorcycle as well as visibility.

Is minimizing the risk to health and life the real reasons for paternalistic laws? What about peoples choices to smoke, or their choice whether or not to wear a seat belt while driving?

Recently, the actor, John Travolta had his son, Jett, die from hitting his head while experiencing seizures from Kawasaki disease. Mr. Travolta is a member of the Church of Scientology. It is believed that this church does not condone the use of medications which possibly could have prevented Jett from having seizures. Jett was 16 years old when he died. Should the doctors have intervened in this case?

Bioethics: Nature and Scope, Sources of Problems and Concern

Euthanasia:

I agree with the author that euthanasia is society's problem, and that it is against The Hippocratic Oath. However, why should the doctor in these modern times exercise paternalism when the patient is over 18 years old, considered an adult by society, of rational mind, and not coerced by wanting relatives to make the adult choice to live or to die -- is it not their life? Where are the patient's rights? Patients should have a choice as long as the patient has been thoroughly evaluated by experts and informed of alternative possibilities of how to live that their life may not truely be over just because they think it is; What about Stephen Hawking, the physicist genius, with Lou Gehrig's disease/ALS that is still making the best of his life although in the advanced stage(s) of ALS -- he considers himself "lucky" despite his disease and its slow progression which allowed him to make more influential discoveries.

The Hippocratic Oath

The Hippocratic Oath:
In the world, medicine is becoming more and more diverse. Information is being shared via computers and international broadcasts. There are different religions, cultures, values, and beliefs to consider. Likewise, there are also different thoughts on healing other than the ancient Greek concept of healing by the "Father of Western Medicine" -- Hippocrates. What about eastern, psychological, divine, natural and other types of healing? Modern science recently confirmed concepts of Eastern Medicine like acupuncture to be valid, and the many great advances in modern surgery, are these not to be considered. As commendable as this oath may be it was sworn in the presence (witnessed) of Greek gods and godesses that are refuted by most religions of the world. Can The Hippocratic Oath apply to todays modern world? Should this oath be the foundation for a more conclusive, multi-healing oath that can be used by the international community at large?

Inaugural Post

Hello, and welcome to Just Another Biomedical Ethics Blog, a weblog for my course on biomedical ethics. We will use this blog as a way to relay class information, and as a forum for writing and discussion.

Each week several students will be assigned to briefly summarize and comment on the readings. The rest of the class is assigned (among other things) to read and and comment on the chosen authors' posts. These are intended to be discussions of questions and problems raised by the author--not necessarily criticism of the author's post itself.

A portion of each student's participation grade will depend on his or her contribution to the blog. For several examples of academic blogging, see the following:

• Cosmic Variance
  
• Crooked Timber
  
• Philosophy, et cetera
• Balkinization

As always, if you have any questions, please feel free to contact me at the email address listed on the syllabus. Happy blogging!