Like human dignity, autonomy is a word more honoured than analysed, even though it is the cornerstone of most contemporary bioethics approaches. In the latest issue of the journal Bioethics, Kam-Yuen Cheng, of HKU SPACE Community College, in Hong Kong attempts to describe what can limit autonomy.
His first assumption, which is widely shared, is that we are as autonomous as we are rational. Hence there are three main conditions which could impair the autonomy of a patient's medical decision: insufficient information, irrational beliefs/desires, and influence of different framing effects.
Providing enough information for patients to make decisions about their welfare can be a challenge, but it is relatively straightforward.
How irrational beliefs and desires limit rationality is more controversial. The most frequent example is Jehovah’s Witnesses’ attitude to blood transfusions. They believe that they will go to hell if they have a transfusion. Since this is (according to Cheng and his mentor Savulescu) irrational, a Jehovah Witness’s autonomy is compromised. So, in most cases, “to respect the autonomy of JWs is to give them life-saving blood transfusion”.
How about dangerous activities like skydiving or smoking? These are irrational, but “Since irrationality admits of degree, the irrationality of players of dangerous sports and smokers is just not high enough to render their deplorable activities non-autonomous.” However, it turns out that while the desire to smoke is irrational, the desire to die can be rational as long as it is done for values which are comparable to life, such as “happiness, dignity, tranquility, etc.” This argument is put forward en passant, but it raises questions about euthanasia and assisted suicide which are not easily answered.
The third limitation is the influence of framing effects, or the possibility of a patient making mistakes in deliberating complex options. Doctors, argues Cheng, should nudge them toward the right decision by presenting treatment options in persuasive perspectives.
The interesting feature of Cheng’s paper is the controversial scenarios which could follow. In some instances, doctors will end up deciding whether or not beliefs are rational. For instance, if euthanasia were legal, doctors might decide that some patients are being irrational in clinging on to life. Or doctors might feel obliged to frame a patient’s condition in ways that persuade her that life is not worth living.
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