Respect for Autonomy
Respect for the autonomous choices of persons runs as deep in common morality as any principle, but little agreement exists about its nature, scope, or strength. We use the concept of autonomy in this chapter to examine individuals’ decision making in health care and research, as patients and as subjects, now often called “participants.”1Although we begin our discussion of principles of biomedical ethics with respect for autonomy, our order of presentation does not imply that this principle has moral priority over other principles. We do not hold, as some critics suggest, that the principle of respect for autonomy overrides all other moral considerations. Furthermore, we attempt to show that, in a properly structured theory, respectfor autonomy is not excessively individualistic (thereby neglecting the social nature of individuals and the impact of individual choices and actions on others), not excessively focused on reason (thereby neglecting the emotions), and not unduly legalistic (thereby highlighting legal rights and downplaying social practices and responsibilities).
THE NATURE OF AUTONOMY
The word autonomy, derivedfrom the Greek autos (“self’) and nomos (“rule,” “governance,” or “law”), originally referred to the selfrule or self-governance of independent citystates. Autonomy has since been extended to individuals, but the precise meaning of the term is disputed. Personal autonomy encompasses, at a minimum, selfrule that is free from both controlling interference by others and from certain limitations suchas an inadequate understanding that prevents meaningful choice. The autonomous individual acts freely in accordance with a self-chosen plan, analogous to the way an independent government manages its territories and establishes its policies. A person of diminished autonomy, by contrast, is in some respect controlled by others or incapable of deliberating or acting on the basis of his or her desiresand plans. For example, cognitively challenged
individuals and prisoners often have diminished autonomy. Mental incapacitation limits the autonomy of a severely retarded person, whereas coercive institutionalization constrains the autonomy of prisoners.
Virtually all theories of autonomy view two conditions as essential for autonomy: liberty (independence from controlling influences) andagency (capacity for intentional action). However, disagreement exists over the meaning of these two conditions and over whether additional conditions are required.2
Theories of Autonomy
Some theories of autonomy feature the abilities, skills, or traits of the autono¬mous person, which include capacities of selfgovernance such as understanding, reasoning, deliberating, managing, and independentchoosing.3 However, our focus in this chapter on decision making leads us to concentrate on autonomous choice rather than on general capacities for governance and selfmanagement. Even autonomous persons who have selfgoverning capacities and are generally good managers of their health sometimes fail to govern themselves in particular choices because of temporary constraints caused by illness,depression, ignorance, coercion, or other conditions that restrict their options. An autonomous person who signs a consent form for a procedure without reading or understanding the form can act autonomously, but fails to do so. Of course we could redescribe the act as one of placing trust in one’s physician, which could be an autonomous act of authorizing the physician to proceed; but it is not anautonomous authorization of the procedure because it is not informed regarding the procedure. Similarly, some persons who are generally incapable of autonomous decision making can at times make autonomous choices. For example, some patients in mental institutions who cannot care for themselves and have been declared legally incompetent may still make some autonomous choices, such as stating...