The principle of autonomy: a new perspective

Enrique H. Prat.
Closing conference of the Master's Degree in Bioethics, Pamplona, 23-V-2009.

At the end of January last year, the global economic elite gathered in Davos for the annual meeting of the World Economic Forum were waiting with bated breath for the message of the Forum's Founder and Chairman, Klaus Schwab. It was clear that he had to address the current economic and financial crisis. What was most surprising was his proposal to follow the model deontology of the medical profession and to develop a Hippocratic code of ethics for businessmen. The idea came as a particular surprise to doctors, because it is precisely at a time when they are allowing the Hippocratic principles of their deontological tradition to be thrown overboard that the professional body of businessmen is attempting to adopt them as a means of overcoming a global economic crisis of hitherto unknown magnitude, no less.

Hans Martin Sass, who, because of his close relationship with Georgetown University - the cradle of bioethics - was a major importer of American bioethics to Europe, was pleased to say in 1992 that paternalism had been definitively overcome in the doctor-patient relationship and that modern medical ethics had transformed the Hippocratic maxim "aegroti salus suprema lex" into "aegroti voluntas suprema lex "1, i.e. the patient's health was no longer the supreme law but the patient's will.

Bioethics has developed a medical ethics that breaks with the centuries-old Hippocratic tradition. Its starting point are four fundamental principles: the principle of autonomy, the principle of beneficence, the principle of non-maleficence and the principle of justice. This quadriga of principles was developed in the 1970s in the United States and is the foundation of the new discipline biomedical ethics, later simply called bioethics.

Indeed, since 1979, when the first edition of Beauchamp and Childress' Principles of biomedical ethics was published, these principles have reached the status of unquestionable dogma, if not dogma, then at least budget , in many areas of bioethics. What is really new in this conception of medical ethics, in contrast to the Hippocratic tradition, is not really the emphasis on the principle of autonomy, which is considered the most important of the four, but the utilitarian approach of this new discipline. The four principles are in fact already found in the corpus hippocraticum. But in the new utilitarian context these principles are no longer what they were in the Hippocratic context. Although there are other conceptions of bioethics, e.g. the so-called personalist bioethics, it must be said that the utilitarian, also called principlist, conception is the one that has dominated the academic field in recent decades.

Indeed, the corpus hippocraticum does not state the principle of autonomy, but what permeates this multi-secular ethics is respect for human dignity. And man's dignity is based on his freedom and therefore on his autonomy and self-determination, but not as understood by principlism, but rather in the sense of the Aristotelian tradition, of the capacity to choose the good. Autonomy that is not in accordance with reason, that is unreasonable, ceases to be autonomy and becomes heteronomy. This is also the meaning of the Kantian definition of autonomy as self-legislation of reason2. In other words, autonomy is also a Hippocratic principle, but not in core topic utilitarianism.

But the approach of principled bioethics has not come as a surprise from heaven, but is a product of modernity which, in the Anglo-Saxon sphere, where the liberal-individualist conception of man predominates, provokes a mutation of the Kantian ideal of autonomy into a radical right to self-determination.

The ethical approaches of modernity are those of the so-called third person. In other words, those in which the subject of ethical reflection stands outside the action and contemplates it, without becoming involved in it, in order to seek general criteria that serve to judge it. These are approaches such as Kant's deontological approach, Bentham's utilitarian approach and the ethics of speech of Habermas or Rawls. The dominant branch of bioethics is constituted as the ethics of the third person, which integrates elements of all three approaches.

Medical ethics, on the other hand, had until the last century been a doctor's ethics, elaborated in the first person. It is the doctor himself who reflects on his professional work. No other profession since antiquity has been as intensely concerned with its moral identity as physicians. No one has been able to combine the cultivation of their art or science with what I like to call the cultivation of conscience. And they have made excellent ethics of the first person, virtue ethics par excellence. It is not surprising that among the great doctors there are great philosophers such as Karl Jaspers, Heinrich Schipperges, Gregorio Marañón, Viktor Frankl, Pedro Laín Entralgo, Juan Bautista Torelló, Edmund D. Pellegrino and Gonzalo Herranz.

It is not easy to give a purely academic explanation for the fact that in the face of the medical profession's efforts to defend its deontological profile and the prominence of its main exponents, this first-person ethics developed by doctors for doctors is increasingly in the hands of philosophers, bioethics professionals with little medical skill , who find it not impossible, but more difficult to reflect in the first person on medical actions and transform it into a third-person ethics, with all the practical drawbacks. However, it is a fact that today bioethics is leading medical ethics.

Returning to the principles, in bioethics the principle of autonomy is understood rather negatively, i.e. not as the capacity for self-determination in accordance with reason, but as the School to decide without coercion, and therefore also without anyone else's coercion. For thirty years, bioethics has been concerned primarily with this principle, which, as mentioned above, in the context of a liberal individualistic conception of man, becomes a radical autonomy in two senses: freedom becomes arbitrariness and what is only a right becomes the individual's obligation to self-determination.

Only twenty years after the beginnings of bioethics, in the USA, this radical conception of the principle of autonomy has begun to be questioned, which in the meantime, in many countries, has been included in the legal regulation of the doctor-patient relationship3. profile But it is a fact that the doctor-patient relationship has abandoned the traditional paternalistic model , in which, if you like, Hippocratic ethics is anchored, opting instead for a contractual model in which the doctor assumes the role of an expert service provider, while the patient acquires the characteristics of a client, or at least some of them.

In this sociological context, bioethics has considered the principle of autonomy from the doctor's perspective and formulated the duty to respect the patient's sacrosanct right to self-determination: "voluntas aegroti suprema lex". It is a question of defining the doctor's duties: how should the doctor inform the patient, so that the patient can exercise his or her right to self-determination? What is the doctor forbidden to do, so as not to influence the patient's decision "too much"? What obligation does the doctor have to know the patient's will, or, if necessary, to get the patient to express his or her will? Under what circumstances would the doctor be allowed to refuse to carry out the patient's will?

In the context of Hippocratic ethics it did not make much sense to speak of the patient's perspective, as the physician assumes all responsibility and duties. In a contractual paradigm this changes and it becomes necessary to reconsider this relationship and to approach the principle of autonomy from the patient's perspective. It is striking, however, that bioethics, in proposing the contractual model as appropriate to the principle of autonomy, speaks only of the patient's rights and the physician's obligations, and not of the physician's obligations. A good ethical theory of autonomy should include this other perspective.

Autonomy, self-determination, is a prerogative of the person. The sick person is a person, i.e. a rational individual, with immeasurable dignity. But man, and also the sick person, is a relational, social being, who is in dialogue with many other beings in his environment. The "I" presupposes a "you". But above all a "you", whom it recognises and loves and from whom the "I" is recognised and loved; for to love and to be loved are the primary needs of every person. Each individual acquires his or her profile and identity in a continuous process, in dialogue with his or her environment. It would be naïve to think that the environment has no influence on him/her. It would also be unreasonable not to listen to the benevolent committee and sometimes also, for other reasons, to the malevolent.

The relational dimension is especially important in the sick person, who is a suffering being and needs financial aid, especially from the doctor. But he or she also needs the physical and spiritual care of nurses, a chaplain and, in any case, the family environment. True autonomy, self-determination, is therefore realised in an emotional context that is best expressed in the first person plural: "we have thought", "we want", and in this "we" the whole relational environment of the sick person is included to varying degrees of integration. Autonomy in the radical solitude of an individual who isolates himself from his environment is contrary to reason and would therefore be heteronomy.

The question therefore arises as to whether the concept of autonomy in bioethics is compatible with the anthropological dimensions of man that I have just outlined. There are more than a few who think that it is not compatible and that this radical autonomy goes far beyond the real possibilities in which many patients and even the healthy find themselves. As Charles Taylor4 has pointed out, it has been the radical individualism of modernity which, by constructing a new Olympus of reason, has forced man to consider individually the problem of his identity, which until then had been a social question. What is new in modern society is that the individual, left alone with his reason, in addition to having to find an original identity on his own, is obliged to struggle to have it recognised by others. Therefore, MacIntyre is right when he affirms, along the same lines as Taylor and many others, that while in pre-modern times identity was deduced from the established categories and principles inherent to the same social structure that were recognised by all, in modern society with "the democratisation of all Structures and of the self, the self no longer has any necessary social content and is deprived of a social identity that it needs".5 There are therefore plenty of reasons to think that in modern society, the self no longer has any necessary social content and is deprived of a social identity that it needs. There is therefore every reason to think that this conception of autonomy is inhuman.

In applying this concept of autonomy to the individual patient, it must be borne in mind that in today's medicine the concept of the patient is also in crisis. When medicine gives entrance to treatments and surgical operations aimed at enabling new lifestyles, or changing the somatic identity of the patient, then the classic aims of medicine - to cure, relieve and comfort - are blurred and medical rationality, based on the principle of beneficence and non-maleficence, is transformed into a contractual economic rationality of service provision. As a result, we now have two types of patients, the patient and the client. But these two types of patients do not exist in a pure form, but in every doctor-patient relationship both types can exist, which complicates the issue. This topic is being studied by many institutions. What is becoming increasingly clear is that medical ethics must take more account of the ethics of the patient, and bioethics should consider the principle of autonomy from the patient's perspective.

The principle of autonomy has always been formulated and considered in bioethics from the doctor's perspective, and no consideration has been given to what this right of self-determination means for the patient, which, seen from the doctor's perspective, becomes a de facto obligation for the patient to self-determine. Because what is expected of the patient is that he makes his own decision, thereby removing the doctor's moral and, above all, legal responsibility.

From the patient's perspective, the question is to what extent a sick person is in a position to make a decision affecting his or her health on his or her own. The question is important because the patient's will - rightly or wrongly - once formally expressed and not corrected, is legally binding on the doctor, and only the patient himself can revoke it.

But what does it mean to decide with autonomy? Autonomy is not arbitrariness. A person acts autonomously when he freely chooses what he should morally choose, i.e. follows the dictates of his right reason. Precisely because it is his reason, if it is right, he acts autonomously. If he decides wrongly, it will be because he is not acting according to right reason. The latter will be flawed for some reason, and the subject will no longer follow the dictates of his right reason. Sooner or later he will realise that it is not what he really wanted: he is not autonomous, but heteronomous. Of course, neither is he autonomous who, against what his right or flawed reason dictates, is forced to opt for what he does not want. It is common among us mortals - healthy or sick - that after having decided and having acted, we realise that the decision and the action were wrong, and that we have acted hastily, perhaps obsessed by affections that are not ordered by reason. The decision was not well thought out, it was not a product of right reason, which, beset by emotions and affections, could not fulfil its mission. We then say: "I was stubborn", "I let myself be influenced", "it wasn't me". These are judgements that express heteronomy.

The sick person is very much turned in on himself; it is natural. He is usually under the influence of a certain shock, and suffers from physical or mental pain. It is doubtful whether, under these conditions, he can, on his own, achieve the necessary distance from the subject he has to judge, in order to do so correctly, free from more or less disturbing apprehensions, fears and anxieties. attend to this patient in his decision making, and even in some cases to make the decision for him, is not a lack of respect for the dignity of his person, but a humanitarian duty of charity. The prudent and wise patient is usually sincerely grateful for this attendance.

In the light of these data we ask ourselves: what is the point of asking the patient in so many European and American hospitals to sign long forms confirming that he or she wants the medication offered after having read the list of possible side-effects? If autonomy is reduced to informed consent and this is achieved in the way described above, this autonomy is an unworthy farce. I say unworthy because what is achieved with this formal modality of realising the patient's right to self-determination is little more than a pretext for shifting the moral responsibility for the medical act onto the patient.

To return to the patient's perspective: how should a responsible person behave in the case of a more or less serious illness? In fact, the answer is not given by bioethics but by virtue ethics. Let me put special emphasis on the thesis that bioethics needs virtue ethics in order to become a truly practical discipline . The virtue chapter, which was perfectly integrated in the medical ethics of the Hippocratic tradition, does not appear in bioethical approaches.

reference letterIn relation to the exercise of patient autonomy, special mention should be made of the virtue of prudence, which in some languages and also on Spanishis translated as wisdom. Prudence is, as is well known, the virtue that perfects reason internshipand is defined as acting according to right reason (recta ratio agibilium). It is a primordial virtue for everyone, and not least for the sick, especially in the most critical situations.

As St Thomas Aquinas has described the act of the virtue of prudence is threefold: consilium, iudicium et imperium. First of all, the committee. It seems to me that this is the element core topic for the sick person to be able to make a prudent autonomous decision.

The patient is normally supported by two relational environments: the family environment and the medical-health environment. Both environments are fundamental for their decisions and for obtaining good advice. In the family environment they will find the right emotional support, the accurate committee of those who love them well and financial aid to overcome painful and difficult situations. The medical-health care environment is mainly concerned with medical and nursing care, which usually goes beyond the purely technical to the emotional sphere, fostering trust and giving comfort and hope. The prudent patient will be able to seek advice in these environments. In his or her decision, he or she will be able to integrate the medical, health and emotional skill of family, doctor and nursing staff. Uexküll and Wesiak put it in their famous guide of Psychosomatic Medicine: "The patient's relationship to the people around him, to his family, his circle of friends and professional colleagues is an integral part of his personality. The quality of these relationships is decisive for their well-being and health. ... These relationships are decisive in the process of restoring health, but also in helping the sick person to make autonomous decisions "6 . The social dimension of the person entails a moral obligation to take the environment into account in decisions. This applies to everyone, whether healthy or ill, but especially when the capacity to make decisions is reduced. It is a fact of general experience, but especially of clinical work, that the sick person with impaired physical and/or mental Schools needs especially the financial aid of his family, friends, medical and nursing staff to realise the autonomy of which he is capable. In such a situation, it would be extremely imprudent for the patient not to allow himself to be helped, just because he does not want to be influenced. It would also be inhumane in such situations not to give the patient in need, with the gentleness and empathy appropriate to each case, the help he or she needs, attendance .

In concrete terms, what are the decisions to be taken by the prudent patient? Let me make a distinction here between first-order autonomy and second-order autonomy. The first concerns decisions on concrete measures to be taken: taking a medicine, having an injection, or even deciding on a medication or treatment. Second-order autonomy refers to decisions made about how to take first-order decisions. These can be diverse, but the fundamental one is to decide which doctor to trust, and once this trust has been achieved, to place the first-order decisions in his or her hands. This does not mean that information on disease progression, treatment and medication, which is crucial to maintain the trust that allows first-order decisions to be placed in the hands of the doctor, should be Withdrawal . While first-order decisions must be made on the fly, as the situation demands, higher-order decisions are well-matured, stable, long-term dispositions that are an expression of the person's identity.

The prudent patient will first of all make a second-order decision with the help of financial aid and advice from people he trusts in his family and medical environment. Being a decision that in some way affects the patient's health, it cannot be taken lightly. If the decision is well taken and trust in the medical team is maintained, the patient is spared the inconvenience of having to control all treatment suggestions and will maintain his or her autonomy very effectively. Does the patient also have to make the first-order decisions? It is clear that without their consent there can be no treatment, but consent for all first-order decisions that need to be made may already be implicit in a second-order decision.

There is an insurmountable asymmetry in the doctor-patient relationship. The patient is not generally an expert in medicine and, however complete the information he or she receives in each case, does not have the medical skill to make the decision. On the other hand, they do have the skill to search for and find a doctor in whom they can place their trust. If this second-order decision is the right one, he will be able to respond calmly to any demand for a first-order decision with a ratification of the second-order decision: "You have my trust, decide what is best". This decisional structure is fundamentally the same as in any asymmetrical professional relationship, such as that of the lawyer-client. But only in the doctor-patient relationship is there the particularity that one party puts his or her life and existence in the hands of the other. But the patient exercises his autonomy perfectly well by limiting himself to making a second-order decision. This does not mean that they abandon themselves completely into the hands of the doctor, but rather that once they have chosen him and made their tastes and preferences known to him, they place themselves in his hands so that he can decide on the most appropriate means of achieving the goal that they have worked out together. Communication between doctor and patient must therefore continue, as this is the only way to consolidate trust, on which the possibility of non-intervention in major decisions is based. When the patient fails to establish a relationship of trust with the doctor and continually intervenes in first-order decisions, he or she runs a high risk of being wrong, even if a second opinion is sought.

What are the limits of autonomy from the patient's perspective?

The legislation of most countries grants the patient with the capacity to decide the right to refuse medication, even if such a decision is contrary to medical rationality, the ethical sense of the medical profession and the conscience of the physician. From the perspective of positive law, it has been consistently stated (e.g. Birnbacher and Dabrock) that "neither freedom of conscience nor the medical skill and its code of ethics can justify a limitation of the patient's right to self-determination "7. This also applies when the refusal leads directly to death. The patient knows that he is protected: the doctor is not entitled to do anything without his consent. But this in no way implies the moral legitimacy of the patient's refusal. This question is usually left open in bioethics. Legal rationality and ethics are different, as is evident in this case.

From the patient's perspective, what does the maxim "voluntas aegroti suprema lex" mean? Is it permissible for the patient to ask for anything and refuse anything he or she wants? This maxim, which is addressed only to the physician, does not imply that the physician is obliged to comply with any wish, even if it is against his conscience, e.g. because it is harmful to the patient's health. For the patient, it means that nothing will be done without his or her consent, but not that he or she has the right to demand whatever treatment he or she wishes. A physician may also refuse to treat a patient for reasons of conscience, except in an emergency.

He who opts for the unreasonable, whether consciously or unconsciously, is not truly autonomous, he has at most the illusion of self-determination, but he is basically heteronomous. If he does so, it is because he does not realise that he is acting in error; if he did realise it, he would not do it. This is what heteronomy is all about. The first fundamental principle of morality "do good and avoid evil" applies first and foremost to oneself. It is no longer reasonable in itself to do whatever we can think of. The fundamental question to be solved by ethics financial aid is to distinguish between the good goal, the true good, and the only apparent good, the appearance of good. This is the main task of virtue ethics. Virtuous action is always autonomous, non-virtuous action is heteronomous. I insist that bioethics as an ethics of the third person always needs the complement of virtue ethics which is an ethics of the first person and which not only tells us what we should do but also how we manage to do what we should do.

The prudent patient is aware that a situation may arise in which he is physically or mentally unable to express his will in a reasonable manner. His declaration could be taken as an autonomous expression of his will, which would oblige the doctor to act accordingly, but because he is in a critical physical and psychological situation, it is not really what he wants. We ask ourselves: who protects the patient from himself? The law does not protect him in such a case, and neither does the doctor, who, just in case, will tend to take the even unreasonable declaration of will seriously as if it were truly his own. The patient is not insane and no doctor will dare to certify him as such. In this case, prudence will lead the patient to appoint a person he trusts - usually a family member - with whom he will agree all his declarations of intent and even, if necessary, leave the decision in the hands of this representative for the duration of the critical situation. The prudent patient shall document in writing who is his or her authorised representative in such circumstances.

Unfortunately in our individualistic and atomised society more and more sick people have no one they can really trust, and families are unfortunately less and less able to take on their most genuine function of attend, comforting, strengthening their members in a state of serious illness, helping them to make decisions and sometimes making them for them. Here we see once again that something is wrong with our society. No matter how much organised solidarity there is, the family is irreplaceable: only the family can guarantee that the sick person's dignity is respected until the moment of death.

I conclude: My critique of the mainstream conception of the principle of autonomy in bioethics is in turn a call to continue to cultivate this other bioethics that meets the following three characteristics:

1. Integrate within it a medical ethic faithful to a twenty-four century old tradition, which is not a stagnant tradition, but one that has evolved with progress in the field of medicine.

2. It places at the centre of its reflection the dignity of the person and therefore also the unquestionable duty to respect his or her freedom. It will therefore be a bioethics that is personalistic, if you will, but never utilitarian.

3. It relies heavily on virtue ethics.

This appeal is not addressed to this University which, against the tide, is doing excellent bioethics, which from the beginning has had these three characteristics.

I feel the need to take this opportunity to thank this University for the work it has done for the benefit of so many other centres around the world. The Imabe-Institut is one of them.

Notes