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.