Hustings Center Report, November-December 1996

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Can the Moral Commons Survive Autonomy?

erhaps nothing has so exasperated me over the years as the deference given in bioethics to the principle of autonomy. To be sure, those who espouse the moral theory of principlism have always insisted

that autonomy is only one among other important principles (that is, justice, beneficence, nonmale- ficence), a l w a ~ to be balanced against them. But my own observation is that autonomy has had far and away a pride of place in practice. Justice has given it some competition, but most contemporary theories of justice (for example, Rawls) have an in- dividualistic point of departure anyway and most renderings of beneficence have had about them the flavor of religion or g o o d y g h e s s , sure losers in the secular world of public policy.

Now, no one in our society, including me, wants to say that individual liberty is not a high value. I prize it and so should everyone else. It is the cor- nerstone of our laws, many of our valuable customs, and a necessary ingredient of any viable theory of human rights. Given that background, it is perfectly understandable that American bioethics should pick up autonomy and run with it. What is less under- standable, more disturbing, is the preemptive role it too often has come to play, and with that a d k tressing exclusionary function. It is not just what autonomy lets in that is the problem, but what it pushes out, whether inadvertently or not.

I locate the main problem in what I take to be the working public policy axiom of autonomy: if someone wants something, and no direct harm can be shown to result, then he or she should be al- lowed to have it. Since it is usually easier to identlfy benefits than harms, particularly long-term harms, autonomy is thus able eady to preempt the high ground. Moreover, because of the cultural power of autonomy there is often little incentive to look hard for possible harms or, even if some can be iden- tified, to let them take precedence. Every benefit of every doubt is given to autonomy. Although it has very Werent historical origins, the idea of individ- ual patient benefit often works together with auton- omy to play an exclusionary role: that of ruling out population benefits and harms in making clinical decisions.

I offer two cases. One is artificial reproduction. In that case, whether it be artificial insemination or

egg donation or surrogate motherhood, the auton- omy of the would-be parent has &fact0 triumphed over all moral objections. It has been hard to prove long-term harm-which we will have to experience first to have it count-and even harder to make the case that those possible harms should override in- dividual choice. I believe that the first wrong step in artificial reproduction, taken years ago, was the acceptance of anonymous sperm donations. To me that is a way of downgrading fatherhood and of vie lating a basic moral principle; through sperm dona- tion a man is allowed to become a biological father but is not held responsible for the consequences of his act. What odds would the bookies in Las Vegas give on the likelihood I can successfully make that case in our society (or even among most of my bio ethical colleagues)?

My second case is resource allocation. There is. now perfectly solid evidence that the best way to improve population health is through public health measures, including health promotion and disease prevention. There is no less solid evidence fiom the experience of the European countries that the best way to hold down health care costs is to have global budgeting and tight controls on the use of technol- ogy. But in our country so powerful is the claim of autonomy and liberty that we are reluctant to use the power of the state to improve public health (smoking is the one exception here). And whenever there is any talk of controlling costs by means of social policy, the prevailing counterargument is al- ways that, in line with American individualism and the Hippocratic tradition, only individual benefit should count in making medical decisions. Given that background, the case for the effective promo tion of public health can hardly get off the ground. Everythmg is stacked against i t e e r y h n g , that is, except the epidemiological evidence.

Can an effective counterweight be found at least to offer autonomy some serious competition? Or, since most of those who espouse principlism hold that the principles can and should conflict with each other on occasion, how can that be made to happen more in practice? I propose two additional princi- ples: the ecological principle and the vital institution principle.

The e&gwulpinc@e-working horizontally, as it were-would urge us to admit no claim of autonomy

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Hartings Center Report, Nwember-December 1996

in medicine until there has been a prior and thorough canvassing of (a) the likely aggregate im- pact of individual choices on m ciety-what will happen if many people do such and such?-and (b) how will autonomous acts in one domain likely interact with autonomous acts in other dc+ mains-what wil l be, that is, the synergistic consequences of a va- riety of autonomous choices? We now know that it is foolish to

look only to how well a new foreign plant does by itself in an old marshland: we need also to know how it will interact with the other plants and what it will do to them. Analogous thinking is necessary in medicine.

The vital instihh p’ncipkorking vertically- would press us to ask about the impact of our autonomous choices on our vital social interests and institutions. If our free reproductive choices will have an effect on the family, on the relationship between men and women, and on childbearing and childrearing, then we should bend over backwards to protect those institutions. Claims of liberty should not prevail so easily as they now do. S i i l y , if population health is a basic goal of a health care system, then claims of liberty should not be allowed to drive up costs with high-technology options or enable the elderly in the future to claim expensive rescue medicine to make up for a lifetime of poor health behavior.

Over-run with claims of autonomy, we are losing the moral commons in medicine. Nothing seems more important than to regain it. rn

Robert M. Veatch

Which Grounds for OverridiHg Autonomy Are Legitimate?

e are in a period when it is as fash- ionable to attack the primacy of W autonomy as it was only a few years

ago to assume its priority. There were good reasons why the bioethics of the 1970s appeared to elevate autonomy to a premier position in the scheme of bioethical principles. Traditional paternalistic Hip pocratic medicine forced us to focus on autonomy. In the early days of The Hastings Center, when Dan Callahan was a young, elfin founder (and I was an

even younger employee), the dominan t moral prob lem in medicine was a paternalistic physician who forced lifeprolonging technologies on a patient or withheld bad news or treated without real consent.

In that world it was proper to conceptualize medical ethics as a tweprinciple system with auton- omy locked in an allaut struggle with individualistic, Hippocratic, paternalistic beneficence. The function of autonomy was not to elevate the focus on the individual. The Hippocratic ethic was already as in- dividualistic as it could be. Its concentration was lim- ited to the isolated individual patient. The function of autonomy was to liberate the patient from the oppression of the physician’s paternalism. Autonomy had a limited role, designed to llfill the transient, narrow purpose of challenging this paternalism.

That is why in the frfeenth year celebration of The Hastings Center I referred to “Autonomy’s Temporary Triumph.”’ And I hold to this day that autonomy should always and without exception win in a simple, flat-out conflict with the individualistic and paternalistic form of beneficent-ven if in a more complex social world autonomy will have to find its rightful more modest place.

Dan Callahan points out that some who espouse principlism in medical ethics insist that autonomy must be balanced against other principles. Surely, he has in mind Tom Beauchamp andJim Child- ress-proponents of balancing competing princi- ples.’ Dan acknowledges this, but fears it does not give enough power to the principles that can limit autonomy.

I think the proper role of autonomy in the sys- tem of principles is more complex than just as one among several coequal principles. For starters, in the stereotypical conflict with Hippocratic paternalistic physician action, I am convinced that even the mod- est position given beneficence by the balancers is too much?

Balancers such as Beauchamp and Childress must concede in theory that in some cases if patient welfare is weighty enough, it outweighs autonomy. I know of no such case. At the level of law no com- petent patient in the United States has ever been forced to undergo medical treatment for his or her own good. I am convinced that this is ethically cor- rect as well. No matter haw tragic, autonomy should always win if its only competitor is the paternalistic form of beneficence.

But, even if autonomy should always win when beneficence to the incompetent patient is its only competitor, surely it must yield-at least some times-when social benefit is at stake. This is the clear, constant call of Dan Callahan. Even here, how- ever, the resolution of conflict among principles is complex. The real question, I suggest, is not whether autonomy can ever be subordinated to other, more social, ethical appeals. Surely it must be. The real question is when autonomy must give way This is the critical moral project for the future of biomedical ethics.

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