oxford handbook of bioethics

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born or that were imposed upon her. Rather, autonomy means living in accordance with rules that one gives to oneself. If an autonomous person does her duty, it is because she has freely and rationally chosen to do so. Autonomy gives an inward turn to moral duty, obligation, or responsibility, grounding them not in nature or history but in the domain of will and rational choice.

OB JEC T IVE AUTONOMY (REASON)

AND SUB J EC T IVE AUTONOMY (LIB ERT Y)

I N BI O ET H I C S

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I

There are, of course, a number of ways in which the concept of autonomy can be used in ethical theory. It can be a good or goal to be obtained in some type of consequentialist theory, but such traits or aspects of human flourishing are usually differentiating concepts, something that only a few can obtain by special effort or circumstance, while autonomy is more commonly taken to be a universal potentiality, a common property or constitutive feature of our humanness as such. If a given individual does not possess autonomy it is rarely taken to be the result of failed effort and more often taken to be the result of some extrinsic condition, oppression, coercion, ignorance, or mental illness, for example. Thus autonomy is often used in deontological or contractarian type theories to designate a condition of mind and agency that adheres to individuals as a matter of right. The right to be allowed to be autonomous is an individual right or moral claim that can be made against others who might interfere with that condition and who thereby have a correlative obligation of non-interference with the autonomy of the other. Whether this is a negative obligation of forbearance only, or also a positive obligation of assistance, is a nice question.

For our purposes here the most important set of theoretical questions about the concept of autonomy concerns the issue of how and on what basis autonomy imposes any moral restrictions on the will of the autonomous person. This has to do with the difference between what might be called an objective understanding of autonomy versus a subjective one. Alternatively, as I would prefer to formulate it, the question has to do with the relative emphasis one gives to reason or to liberty in one’s understanding of autonomy. This difference marks out the two principal pathways within the liberal tradition that the concept of autonomy has followed. The first may be seen in Locke and Rousseau, but certainly finds its most sophisticated philosophical expression in the ethical writings of Kant. The second can be seen as a course charted by John Stuart Mill in On Liberty and pushed even further a century later by Isaiah Berlin in his famous essay ‘Two Concepts of Liberty’.

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against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise or even right. These are good reasons for remonstrating with him, or reasoning with, or persuading him, or entreating him, but not for compelling him or visiting him with any evil in case he do otherwise. To justify that, the conduct from which it is desired to deter him must be calculated to produce evil to someone else. The only part of the conduct of anyone for which he is amenable to society is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.

This shifts the question from the definition of reasonable, rightful choice to the definition of harm and to discriminations among various kinds and degrees of harm. It is not obvious that this latter is an easier concept with which to deal, but harm does have a certain solidity, a naturalistic and tangible quality that the concept of reason seems to lack. Nonetheless, problems abound. Define harm too expansively, and autonomy shrinks. How serious does harm have to be? Is it only serious physical harm or injury, or do psychological damage, pain, and suffering count as well? What is the gradation between harm, offence, annoyance, and inconvenience? Where should we draw the line?

Generally speaking, the species of harm that has most preoccupied bioethics is precisely the denial of autonomy or negative liberty of the other. Closely related, and of special importance in medicine, is the right to privacy and bodily integrity, in a word, informed consent. The autonomy or liberty limiting harms that are most prominent in bioethics are those things that encroach on my private space, those things that I don’t invite in, whether it be an experimental drug, a life-saving surgery, or the implantation of an artificial nutrition and hydration tube that serves to prolong my dying from an underlying incurable disease.

III

There are some limitations on voluntary transactions imposed on grounds of moral standards, to be sure. But they are coming fully into the literature of bioethics only rather slowly, and they tend to come in the area of health policy and questions of the allocation of scarce resources. For example, the insurance system now confounds John Stuart Mill’s distinction between other-regarding and purely self-regarding behaviour. Corporations will soon begin to take a greater interest in the healthrelated behaviours and characteristics of their employees — diet, exercise, smoking, genetic make-up — in order to hold down their insurance costs. This interest poses a substantial threat to the privacy and autonomy of large numbers of individuals in the coming years. But for those bioethicists inclined to justify it, it will be justified, as autonomy as negative liberty holds that all abridgements of freedom must be, on the basis of protecting the rights of healthy, well-behaved, and genetically

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well-endowed employees against the costly profligacy and self-abuse of those who get sick and drive up health care costs. Not because the choices of the profligate are inherently objectionable, but because their social effects cause harm to others.

Nonetheless, it is difficult, when discussing morality, especially within the domain of will, autonomy, and freedom, not to hold out some kind of interpersonal ideal, some notion of what counts as a higher kind of life and a better kind of choice. The tension between objective autonomy and subjective autonomy lingers even today in bioethics, although I believe that it is fair to say that the subjective conception of autonomy, which stresses liberty over reason, holds sway, subject pretty much only to those side constraints that Mill and his liberal successors have placed on it, such as the harm principle, justice, equity, and fairness. This is why it is helpful to consider Berlin as a kind of missing step as we move from Mill to modern bioethics.

One rarely acknowledged source that anticipates, if it did not directly influence, an important intellectual trend in bioethics is the key distinction between negative and positive liberty that was coined and first suggested by Berlin in his ‘Two Concepts of Liberty’.

Negative liberty has to do with establishing a zone of privacy and non-interference around each person, a zone within which the person can exercise his own faculties and pursue his own life in his own way. Berlin (1969: 127) explains the concept this way:

The defence of liberty consists in the ‘negative’ goal of warding off interference. To threaten a man with persecution unless he submits to a life in which he exercises no choices of his goals; to block before him every door but one, no matter how noble the prospect upon which it opens, or how benevolent the motives of those who arrange this, is to sin against the truth that he is a man, a being with a life of his own to live.

Autonomy understood as negative liberty appeals to metaphors of space. It wants elbow room, a place of one’s own. It is the single-family dwelling of ethics. Negative liberty requires fences and boundaries for protection against outside intruders. It rests on a conflict-ridden and antagonistic picture of social existence, in which each individual struggles with everyone else to control his own patch of ground. Negative liberty does not appeal to Napoleons or Don Juans. It appeals to ordinary folks who simply wish not to be dominated, who wish to be left alone.

Autonomy is also linked to liberty in another sense, through what Berlin and others have called positive liberty. Positive liberty is very close to self-mastery and detached judgement. Berlin (1969: 131) explicates it this way:

The ‘positive’ sense of the word ‘liberty’ derives from the wish on the part of the individual to be his own master. I wish my life and decisions to depend on myself, not on external forces of whatever kind. I wish to be the instrument of my own, not of other men’s, acts of will. I wish to be a subject, not an object; to be moved by reasons, by conscious purposes, which are my own, not by causes which affect me, as it were, from outside. I wish to be somebody, not nobody; a doer — deciding, not being decided for, self-directed and not acted upon by external nature or by other men as if I were a thing, or an animal, or a slave

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to (b) the conditions that have been required of it to gain intellectual legitimacy, and thereby some measure of power and influence, in professional and policy domains.

The sociological factor to which I refer is the growing distance in the field between those who practice moral philosophy and political theory in academic settings and the rather insular literature in bioethics that purports to address its theoretical, conceptual, and philosophical underpinnings. William F. May (1980) once quipped that the relationship of the applied ethicist to the moral philosopher was as one who draws and carries water from wells they have not dug. Today that requires amendment. Applied ethicists are digging their own wells and carrying ideas from them to share with professional practitioners in medicine, science, and other fields. However, the new wells are not so deep nor their water always pure. That is perhaps unfair and too harsh. Another way of saying it is that the conditions under which theorizing takes place in bioethics have changed and are different from what they are in philosophy and cognate disciplines. To be in a bioethics centre in a medical school is not the same as being in a philosophy department in a school of arts and sciences. Thirty-five years ago bioethics was made up mainly of individuals who were at home in both places; today few move easily between them.

The problem of legitimacy in bioethics arises from the necessity for the field to make a transition from its origins in movements that arose in opposition to mainstream medicine, health care, and biomedical science to an established consulting discipline that has gained access to both clinical and policy settings. These movements of the late 1960s and early 1970s voiced concerns about obstetric practices and women’s health generally, consumer rights, health care access for the elderly, children, and the poor, and advocacy for persons living with disabilities, and for those mistreated in certain types of medical research, such as the syphilis study conducted around Tuskegee, Alabama, by the United States Public Health Service. An important part of gaining this type of respectability and acceptance, while at the same time avoiding a total and abject co-optation, was to build an ethical stance around a concept such as autonomy that effectively straddled the powerful forces of libertarian individualism in the broader political and moral culture while redirecting the use of the expertise and authority of medicine without fundamentally challenging or undermining that authority. The concept of autonomy, understood as it has been in bioethics as negative liberty, has been well suited to this task. The practice of medicine in the service of respect for the rights, dignity, and personhood of the patient replaces medicine in the service of beneficent paternalism. But in this shift medicine retains its power based on scientific expertise, cultural influence, control over access to medical technology and treatment modalities, and considerable (albeit somewhat attenuated of late by the fiscal crises of universal insurance systems or by the commercial interests of managed care systems in the United States) leverage over the allocation of resources, conditions of practice, lobbying power, and the like.

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CONCLUSION

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The component ideas of autonomy — individual rights, freedom of choice, privacy, independence, freedom from outside interference — are vested with great moral legitimacy. They express deeply felt aspirations and worthy ideals. At the same time, other principles that remind us of our social natures and our interdependence as human beings — community, citizenship, authority, obligation, responsibility, reciprocity, tradition, rules, limits — are also ideas of potent resonance. They are the words of civilization and moral order; they are the elements of an essential vision of the human good. In fact, we perceive them as indispensable, since they are firmly rooted in our psychological natures. These ideas derive from the fact that the human identity is shaped by — and the human good is lived within and through — social roles (such as being a parent), relationships (such as providing care), and institutional structures (such as the family and civic and religious groups).

No moral discourse is truly adequate to the richness of human moral experience if it lacks either vocabulary — the vocabulary of autonomy or that of relationality and mutuality. It is critical that we retain what is of enduring value in the language of liberty and autonomy, but it is no less critical that we sustain the language of responsibilities and relationships. If there is a danger inherent in bioethics today — and I am convinced that there is — it comes from an excessive emphasis on autonomy and too little appreciation of human interdependence and mutual responsibility.

REFERENCES

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BEAUCHAMP, T., and CHILDRESS, J. (1994), Principles of Biomedical Ethics (4th edn. New York: Oxford University Press).

BELL, D. (1976), The Cultural Contradictions of Capitalism (New York: Basic Books).

BELLAH, R. N., MADSEN, R., SULLIVAN, W. M., SWIDLER, A., and TIPTON, S. M. (1985),

Habits of the Heart: Individualism and Commitment in American Life (Berkeley: University of California Press).

(eds.) (1987), Individualism and Commitment in American Life: Readings on the Themes of Habits of the Heart (New York: Harper and Row).

BERLIN, I. (1969), ‘Two Concepts of Liberty’, in Berlin, Four Essays on Liberty (New York: Oxford University Press), 118 – 72.

CALLAHAN, D. (1970), Abortion: Law, Choice, and Morality (New York: Macmillan).

CHARLESWORTH, M. (1993), Bioethics in a Liberal Society (Cambridge: Cambridge University Press).

Compassion in Dying v. Washington (1996), 79 F. 3d 790 (9th Cir.)

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(1980), ‘The Nature and Value of Rights’, in J. Feinberg, Rights, Justice, and the Bounds of Liberty (Princeton: Princeton University Press), 143 – 58.

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GILLON, R. (1986), Philosophical Medical Ethics (New York: John Wiley). HAUERWAS, S. (1974), Vision and Virtue (Notre Dame, Ind.: Fides). HAWORTH, L. (1986), Autonomy (New Haven: Yale University Press).

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O’NEILL, O. (2002), Autonomy and Trust in Bioethics (Cambridge: Cambridge University Press).

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TAYLOR, C. (1991), The Ethics of Authenticity (Cambridge, Mass.: Harvard University Press). THOMSON, J. J. (1971), ‘A Defence of Abortion’, Philosophy and Public Affairs, 1/1 (Fall), 47 – 66; repr. in M. Cohen, T. Nagel, and T. Scanlon (eds.), The Rights and Wrongs of

Abortion (Princeton: Princeton University Press, 1974), 3 – 22.

WOLFE, A. (2001), Moral Freedom: The Search for Virtue in a World of Choice (New York: W. W. Norton).

WOLFF, R. P. (1970), In Defense of Anarchism (New York: Harper and Row).

c h a p t e r 4

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M E N TA L

D I S O R D E R , M O R A L AG E N C Y, A N D T H E S E L F

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J E A N E T T E KE N N E T T

INT RO DUC T I ON

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LET me begin by quoting from Ann Deveson’s account of life with her son Jonathan, who suffered from chronic schizophrenia:

At the end of the afternoon I was driving through North Adelaide when I spotted [Jonathan] walking along the middle of the road. He waved at me to stop. He asked me for a milkshake so we went into a cafe, and talked for a few minutes before he began glowering at me, and muttering. The tension of the past few weeks . . . was bound to erupt sometime. It erupted over me.

One minute Jonathan was blowing into his chocolate malted. The next he had thrown the milkshake into my face, followed by the pepper and salt, upturned the table, and chucked a chair at me. People gasped, the waiter came running and Jonathan shot off, out the door and up the street.

I would like to thank Dean Cocking, Steve Matthews, Franc¸ ois Schroeter, Janna Thompson, and audiences at the universities of Melbourne, Edinburgh, and Glasgow, the Australian Catholic University, and the Australian National University for helpful comments on earlier versions of this chapter.