The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care. (...) The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy. (shrink)

Autonomy is one of the most contested concepts in philosophy and psychology. Much of the disagreement centers on the form of reflexivity that one must have to count as genuinely self-governing. In this essay, we argue that an adequate account of autonomy must include a distinct requirement of accurate self-assessment, which has been largely ignored in the philosophical focus on agents' ability to evaluate the desirability of acting on certain impulses or values. In our view, being autonomous (i.e., self-guiding) involves (...) understanding the extent to which one has the capacities required for one's intended actions. On both clinical grounds (drawn from cases of frontal brain injury) and conceptual grounds, we argue that one's autonomy is diminished to the extent to which one's ability to assess one's capacities is impaired. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.