Moral philosophers and bioethicists have spilled buckets of ink exploring and debating the boundaries of autonomy. It is the nine-headed hydra of modern ethics; with each attempt to limit its reach, it seems to grow new appendages.
As a physician, I am unafraid of stray appendages. Still, nothing in my medical training prepared me for the corrupting power of bioethics’ all-purpose catchphrase—Respect for Autonomy—and the flotsam of deception that churns in its wake.
Before going further, let me acknowledge the obvious: Any properly conceived notion of bioethics must include autonomy as one of its central tenets. Self-determination—the right to make informed choices free from coercive influence—is a foundational principle of biomedical ethics. The patient suffering the ravages of cancer should be free to choose whether the burden of continued chemotherapy outweighs its benefits.
It is not this right-minded conception of patient autonomy that should concern us. What should concern us is its mutated form that, unconstrained by concerns about human nature and normative morality, has morphed from an instrumental means of protecting patient rights to a seemingly unrestrained end in itself.
The Birth of an Ever-Expanding Principle
In 1978, the Belmont Report was published by a US Commission responding to the brutally inhumane Tuskegee Syphilis Study. The Belmont Principles are threefold: Respect for Persons, Beneficence, and Justice. First among these is “Respect for Persons,” which emphasizes the patient’s right to make autonomous choices. Importantly, Belmont’s authors also require medical researchers to respect and protect those who are non-autonomous, such as those suffering from disabling conditions. As conceived in this context, autonomy was a well-circumscribed and inarguable principle: protecting patients from harm while respecting their right to make autonomous choices.
Properly understood, autonomy is constrained by two important factors: human nature and morality. You and I might offer different accounts of these two concepts, but we almost certainly would agree that both are essential concerns in determining the contours and limits of autonomy. So, I must ask: While arguing that we should respect persons and their autonomy, why did Belmont’s authors not define “person”? Why did they sidestep the question of human nature and leave us to wonder who counts as a person?
The answer can be found in this short video. In it, Belmont’s chief scribe, noted Georgetown philosopher Tom Beauchamp, candidly describes his inherent suspicion of the word “person” and the commission’s view that exploring its meaning “was only going to get us in trouble.”
This is worth reflecting upon for a moment. A commission comprising some of the world’s most eminent philosophers, medical researchers, social scientists, and jurists recognized the problem created by Roe v. Wade (which introduced the peculiar and still-undefined concept of “potential life”), but its members chose to look the other way. In so doing, they prevented any conception of human nature from exerting its proper influence on autonomy’s role in bioethics.
A Tectonic Shift—From Protecting Persons to Protecting Freedoms
The Belmont Report was soon eclipsed by Tom Beauchamp and James Childress’s Principles of Biomedical Ethics, which has become a near-scriptural text in modern ethics. It articulates four guiding principles—Respect for Autonomy, Beneficence, Non-Maleficence, and Justice—collectively known as “principlism” and widely regarded as a mainstay of modern biomedical ethics.
The first and most obvious thing to note is how Beauchamp and Childress discarded Belmont’s “Respect for Persons” and replaced it with “Respect for Autonomy.” Physicians are thus instructed to render their respect to a principle rather than to persons. With the stroke of a pen, they shifted the focus from protecting persons to protecting freedoms, thereby pushing human nature and its restraining influence further into the background.
Physicians enthusiastically embraced principlism. There were at least two reasons for this. Unlike Aristotle and Kant, Beauchamp and Childress speak a language that physicians understand. More importantly, the secular character of these principles coincided with medicine’s steady retreat from ethics based on older, “rigid” moral philosophies. In place of traditional Judeo-Christian morality, modern medicine adopted . . . well, nothing. This was one of the early criticisms of principlism—that it had no moral foundation on which to stand—but our postmodern secular society had little interest in this (mostly whispered) concern.
Deciding Who Counts
Autonomy’s radical expression exerts a harmful effect on modern culture not just by its supposed power to liberate us from our perceived shackles, but also by its power to deprive persons of their rights and liberties. Contrary to our longstanding cultural and political tradition, the modern conception of autonomy puts into question the moral status of non-autonomous persons. Moral status must be conferred on us by our fellow citizens; the weak and vulnerable must rely on the goodwill of the strong and powerful. Innate human dignity and its attendant protections are no longer a given.
For some restless philosophers and bioethicists, autonomy and human rights have become potter’s clay to knead and shape into whatever form suits their intuitions. In an essay about the ethics of embryonic stem cell research that appeared in the Journal of the American Medical Association, for example, the authors invoke the principle of autonomy to strip human embryos of their human nature even as they affirm that such embryos deserve our “profound respect”:
One interpretation of such “profound respect” for the embryonic source of stem cells is respect for the “cellular dignity” of these embryos as symbolizing the personal autonomy society already honors in adults.
This is contempt dressed up to look like respect. Human beings at an embryonic stage of life are debased as a “source of stem cells” and—strangely—exalted as a symbol of personal autonomy. It resembles a metaphysical shell game more than it does serious discourse—empty ideas flittering in front of our eyes, trying to divert our gaze from the truth.
Sadly, many physicians are only too happy to defer questions of human nature to philosophers and theologians, but not because they want the answer. Rather, it seems that many don’t want the answer.
I recently attended a state legislative session in which a former Chairman of the Department of Obstetrics & Gynecology at a renowned medical school gave an animated speech about women’s autonomy and the need to protect their right to abortifacient drugs. His scientific defense consisted of defining “conception” as the implantation of the “product of fertilization” (what most people call a baby) into the wall of the uterus—a scientific falsehood fabricated by the American College of Obstetrics and Gynecology and overwhelmingly rejected in a survey of obstetricians. Increasingly, physicians and medical institutions alike feel morally justified in concocting scientific myths to “protect” their patients’ right to autonomy.
But are they really protecting patient rights? Withholding the truth from patients does not serve their interests. Instead, it corrupts the information on which they rely to make autonomous choices. For too many physicians, autonomy has become a higher good than their patients’ right to the truth.
Rebelling Against Our Nature
Too often, the principle of autonomy exerts a corrosive effect on our rational nature. In service to autonomy, feelings replace (rather than complement) intellect. We are told that we must accept a declaration like, “Even though I was born in a boy’s body, I feel like a girl. I have the right to make my body conform to my feelings.” This is one of the most tragic failures of modern medicine. Based on no objective evidence, and contrary to almost every conception of human nature over the past two millennia, many of my medical colleagues have acquiesced to the growing social norm that feelings about gender are reality. This problem goes much deeper than the question of autonomy, but autonomy is the ethical principle almost universally invoked by those undergoing a sex “transition.”
Aristotle and Aquinas taught us that truth is the conformity of our intellect to the things of this world, not the other way around. As physicians, we invoke this idea of truth when treating anorexic teenagers whose bodies “do not conform” to what they feel. We do this because we care about them and want to help them. But pre-adolescent children and young teenagers who feel that their bodies do not conform to their preferred gender are told to embrace and even celebrate this intuition.
When the moral stakes are highest, we degrade patients by treating them as though they were simply bundles of self-interest. Autonomy supposedly entitles us to our passions and impulses, even those that are objectively harmful. An article in the Journal of Medical Ethics, for example, proposes that at least some patients should be permitted to continue to engage in self-harm and self-mutilation (such as self-cutting). Permitting them to hurt themselves in this way supposedly “recognizes their autonomy and accepts that they have a different way of coping with distress.”
Autonomy Has Become a Dangerous Metaphysical Myth
Richard John Neuhaus once characterized bioethics as “an industry for the production of—sometimes elegantly rationalized—permission slips.” The principle of respect for autonomy gives us permission to throw a tantrum against our nature. It “grounds” our freedom not in principles like equality and human dignity, but, rather, the tacit expectation that your freedom will not interfere with mine. Of course, if both of us are grounded in nothing other than non-interference, we are grounded in nothing at all.
The radical form of autonomy that has overtaken our culture is a metaphysical myth, and a dangerous one at that. The reality is this: We are dependent creatures who owe our next heartbeat to a creative mystery over which we have no control. Whether one believes in God or not, our human nature derives from that creative mystery and we are not its authors. Our modern conception of autonomy, which emphasizes human will over human nature and creates hierarchical tiers of moral status, betrays a breathtaking arrogance.
Today, physicians and patients alike stand on the shore facing the onrushing cultural tsunami, and for our protection moral philosophers have placed a leaky water pail in our hand. Physicians have been indoctrinated to believe that we must not introduce our personal moral judgment when caring for our patients. We fear being labeled paternalistic, chauvinistic, or worse, so in the name of respecting autonomy we push aside the law written on our hearts.
As a bioethical principle, respect for autonomy asks far too little of our minds and hearts. Any ethical precept that scrupulously avoids the idea of a universal and immutable human nature is essentially a philosophical ornament. It fails to provide a clear account of those things that are always required of us, and it allows a moral relativism that, as we see, can lead to deceptive and coercive practices that interfere with the exercise of true autonomy.
We can do better—much better—but only if we accept those aspects of our human nature against which we seem to want to rebel: our dependence, our limitations, and, curiously, our transcendence.
Philip Hawley, Jr., MD, is a hospice physician and former Assistant Professor of Clinical Pediatrics at University of Southern California Keck School of Medicine. His novel, STIGMA, was published by HarperCollins.