Principle-based formulations of bioethical theory have recently come under increasing scrutiny, particularly insofar as they give prominence to personal autonomy. This essay critiques the dominant conceptualization of autonomy and urges an alternative formulation freed from the individualistic assumptions that pervade the prevailing framework. Drawing on feminist perspectives, I discuss the need for a vision of patient autonomy that joins relational experiences to individuality and acknowledges the influence of patterns of power and authority on the exercise of patient agency. Deficiencies in (...) the current models of science and social relations guiding medical practice are analyzed, particularly (1) the tendency to disregard the patients self-knowledge and (2) failure to recognize limitations on the generalizability of medical knowledge. Models of social relations such as mothering and friendship are explored to advance a conception of autonomy better suited to the practical activities of medicine. In conclusion, I consider how acknowledgement of the specificity and complexity of social relations can contribute to reconfiguration of other principles comprising the standard framework of bioethics, particularly beneficence, justice, and equality. (shrink)

This essay lays the groundwork for a novel conception of autonomy that may be called “effective autonomy”—a conception designed to be genuinely action guiding in bioethics. As empirical psychology research on the heuristics and biases approach shows, decision making commonly fails to correspond to people’s desires because of the biases arising from bounded cognition. People who are classified as autonomous on contemporary philosophical accounts may fail to be effectively autonomous because their decisions are uncoupled from their autonomous desires. Accordingly, continuing (...) attempts to value patient autonomy must go beyond existing philosophical conceptions of autonomy to consider the background conditions of human decision making. (shrink)

The realities of long‐term care call for a refurbished, concrete concept of autonomy that systematically attends to the history and development of persons and takes account of the experiences of daily living.

The concept of personal autonomy is central to discussions about democratic rights, personal freedom and individualism in the marketplace. This book, first published in 1986, discusses the concept of personal autonomy in all its facets. It charts historically the discussion of the concept by political thinkers and relates the concept of the autonomy of the individual to the related discussion in political thought about the autonomy of states. It argues that defining personal autonomy as freedom to act without external constraints (...) is too narrow and emphasises instead that personal autonomy implies individual self-determination in accordance with a chosen plan of life. It discusses the nature of personal autonomy and explores the circumstances in which it ought to be restricted. In particular, it argues the need to restrict the economic autonomy of the individual in order to promote the value of community. (shrink)

In this eye-opening look at the doctor-patient decision-making process, physician and law professor Jay Katz examines the time-honored belief in the virtue of silent care and patient compliance. Historically, the doctor-patient relationship has been based on a one-way trust -- despite recent judicial attempts to give patients a greater voice through the doctrine of informed consent. Katz criticizes doctors for encouraging patients to relinquish their autonomy, and demonstrates the detrimental effect their silence has on good patient care. Seeing a growing (...) need in this age of medical science and sophisticated technology for more honest and complete communication between physician and patients, he advocates a new, informed dialogue that respects the rights and needs of both sides. In a new foreword to this edition of The Silent World of Doctor and Patient , Alexander Morgan Capron outlines the changes in medical ethics practice that have occurred since the book was first published in 1984, paying particular attention to the hotly debated issues of physician-assisted suicide and informed consent in managed care. (shrink)

Ethical physicians need to share their biases and prejudices and articulate alternatives and also be tolerant of the decisions of their patients and families.I believe that I am a moral, caring, dedicated doctor working with children and parents who are often faced with ethical problems of large and small dimensions. There is no question that these decisions should be ethical, but, in general, I find ethical theory of little day-to-day use. Indeed, even when an ethicist joins me in a discussion (...) of “What should I do?”, or more appropriately, “What should I advocate be done?”, I usually find their additions to the discussion wanting. Ethical theory gives guidance but does not seem to provide sufficient help in decisions for the individual case: What will be best for the infant with spina bifida while still in utero? Termination of the pregnancy? Birth and long-term care? What is best were that same child already born with a high paraplegia and hydrocephalus? What is best for the infant with a major malformation of the brain and uncontrollable seizures whose only hope for controlling the seizures is removal of half of the brain? What is best for the family in each of these situations and the many others I have encountered? What is best for society?I have been called a Hegelian pragmatist, although my knowledge of Hegel is minimal. I think that the term pragmatist is a badge of honour, because, on the front lines of clinical decision-making, I do not have the philosopher’s luxury of days or weeks for managing words. As a pragmatic doctor, I am forced to be a person of action or inaction. I must make a decision and advocate for the position I take.I am clearly a utilitarian, as I strive to produce the greatest good …. (shrink)

The notion of consent which rose to the forefront in biomedical ethics as an attempt to safeguard patients' autonomy, is relatively new. The notion itself requires qualification, for it precludes neither duress nor ignorance. More seriously, I argue here that consent is redundant except in situations where paternalism prevails. Paradoxically, these are the very situations where it may be difficult to uphold or to verify voluntary consent. I suggest that a request-based relationship has the potential to overcome these difficulties. It (...) enhances patients' participation in decision making, requires that the patients remain in command and avoids their subordination. Request is also more conducive to treatments that are representative of patients' own values and perceptions. In practice, what one wants and what one agrees to, often concur. But these are not conceptually identical issues, and they carry important differences of emphasis. (shrink)