Response to Onora O’Neill on Paternalism and Partial Autonomy
Marc Marenco, D.Phil.
Dr. O’Neill addresses an important and long-standing problem in medicine. On the one hand a physician is sworn not only to do no harm, but to do only that which will do good for his/her patients. On the other hand, we all tend to think that “rational adults,” should be able to make choices for themselves, even when we don’t think those choices are best and in fact may bring about some harm. These two commitments can create a classic moral dilemma.
I don’t agree with Dr. O’Neill that there is anything like a “traditional” view of autonomy in medicine. She has not provided any evidence that there is such a standard. She only asserts it. I think it is reasonable to think that physicians and other health professionals are all over the map when it comes to the extent to which they respect autonomy over beneficence in dealing with their patients. This point takes nothing away from her appeal to what he calls “partial autonomy,” however. It only takes away from the idea that Dr. O’Neill is somehow the first to come up with something like the taxonomy we find in her article.
On page 54 O’Neill writes about how Utilitarians like Mill and “action” oriented philosophers like Locke think about autonomy. O’Neill asserts that Mill’s claim that we are the best judge of our own happiness is “dubious” but does not really defend that with anything other than a “PROBABLY many people….” type remark. What I think O’Neill may be missing here is the idea that ownership of one’s choices is in itself part of what drives the perception of happiness. That is, making a wrong choice that is freely made may bring more happiness than an arguably better choice that is imposed from outside. Yes, as in the case of Donald Cowart, forcing treatment against his will eventually led to the restoration of a meaningful if not difficult life. But the resentment at having been forced to undergo treatment remained permanently lodged in his mind and no doubt mitigated the happiness that came from that restoration.
With respect to action oriented ethics, where we look closely at the action itself rather than results, O’Neill says that there is a kind of naiveté in the idea that the assumptions that work in the areas of politics and commerce can also work in medicine. I think she rightly points out that if one looks closely at the conditions under which many if not most patients make choices about their care, the ideal of informed consent by a fully rational adult is rarely if ever met. Informed consent and respect for autonomy in the medical context is a messy business. As he points out on page 54 with her concept of the “opacity of consent,” “All consent is consent to some proposed action or project under certain descriptions. When we consent to an action or project we often do not consent even to its logical implications or to its likely results (let alone its actual results), nor to its unavoidable corollaries and presuppositions.” She rightly points out that we often forget the messiness of true consent and are swept up in the ideal, much to the deficit of patients.
From my point of view, what we are striving for in weighing the two horns of the dilemma between autonomy and beneficence, is not really rational informed consent, but simply that enough information and argument are brought to bear on the situation to satisfy our commitment to not running roughshod over the decision-making processes of other people. In some cases, depending on the consequences that follow from a patient choice, one might bring a great deal to bear to bring about ownership of some course of action. In another case one might be satisfied to stand back, give out whatever information you have and let the proverbial chips fall where they may.
O’Neill then writes about the idea of partial autonomy and reintroduces what she sees as the appropriate use of the paternalism principle. Fair enough. I worked for a year on Winchester II, Yale/New Haven’s cancer ward. It became very obvious very quickly that this was a group of patients with many kinds of vulnerabilities which made them especially prone to the manipulation O’Neill describes. My own view is that when enough factors are present to be persuaded that the capacity for rational decision-making is comprised in ways that have significant consequences, something like a reasonableness standard needs to be applied. That is, when pain, depression, or other motivationally relevant factors are present to the extent that they fundamentally hijack the reasoning processes we can and should do what a ‘reasonable person’ would want under the conditions of the patient in question.
O’Neill’s point seems to be this. “What we have are patterns of reasoning which yield different answers for different patients and for different proposals for treatment.” (page 58) It is hard not to agree with this observation and hard not to say something like, “obviously…” As I wrote in the beginning, I think that how medicine proceeds in the real world is already something like what O’Neill writes about here.
I have no quarrel with the list of types of partial autonomy O’Neill writes about in her final section. They seem to me to represent bona fide differences in situations which require commensurate differences strategies to reach that point I described earlier where one is satisfied one has not simply run rough shod over a person’s wishes while nevertheless bringing to bear arguments and persuasion proportionate to the consequences of a “bad” choice.”
Marc Marenco, D.Phil.
Dr. O’Neill addresses an important and long-standing problem in medicine. On the one hand a physician is sworn not only to do no harm, but to do only that which will do good for his/her patients. On the other hand, we all tend to think that “rational adults,” should be able to make choices for themselves, even when we don’t think those choices are best and in fact may bring about some harm. These two commitments can create a classic moral dilemma.
I don’t agree with Dr. O’Neill that there is anything like a “traditional” view of autonomy in medicine. She has not provided any evidence that there is such a standard. She only asserts it. I think it is reasonable to think that physicians and other health professionals are all over the map when it comes to the extent to which they respect autonomy over beneficence in dealing with their patients. This point takes nothing away from her appeal to what he calls “partial autonomy,” however. It only takes away from the idea that Dr. O’Neill is somehow the first to come up with something like the taxonomy we find in her article.
On page 54 O’Neill writes about how Utilitarians like Mill and “action” oriented philosophers like Locke think about autonomy. O’Neill asserts that Mill’s claim that we are the best judge of our own happiness is “dubious” but does not really defend that with anything other than a “PROBABLY many people….” type remark. What I think O’Neill may be missing here is the idea that ownership of one’s choices is in itself part of what drives the perception of happiness. That is, making a wrong choice that is freely made may bring more happiness than an arguably better choice that is imposed from outside. Yes, as in the case of Donald Cowart, forcing treatment against his will eventually led to the restoration of a meaningful if not difficult life. But the resentment at having been forced to undergo treatment remained permanently lodged in his mind and no doubt mitigated the happiness that came from that restoration.
With respect to action oriented ethics, where we look closely at the action itself rather than results, O’Neill says that there is a kind of naiveté in the idea that the assumptions that work in the areas of politics and commerce can also work in medicine. I think she rightly points out that if one looks closely at the conditions under which many if not most patients make choices about their care, the ideal of informed consent by a fully rational adult is rarely if ever met. Informed consent and respect for autonomy in the medical context is a messy business. As he points out on page 54 with her concept of the “opacity of consent,” “All consent is consent to some proposed action or project under certain descriptions. When we consent to an action or project we often do not consent even to its logical implications or to its likely results (let alone its actual results), nor to its unavoidable corollaries and presuppositions.” She rightly points out that we often forget the messiness of true consent and are swept up in the ideal, much to the deficit of patients.
From my point of view, what we are striving for in weighing the two horns of the dilemma between autonomy and beneficence, is not really rational informed consent, but simply that enough information and argument are brought to bear on the situation to satisfy our commitment to not running roughshod over the decision-making processes of other people. In some cases, depending on the consequences that follow from a patient choice, one might bring a great deal to bear to bring about ownership of some course of action. In another case one might be satisfied to stand back, give out whatever information you have and let the proverbial chips fall where they may.
O’Neill then writes about the idea of partial autonomy and reintroduces what she sees as the appropriate use of the paternalism principle. Fair enough. I worked for a year on Winchester II, Yale/New Haven’s cancer ward. It became very obvious very quickly that this was a group of patients with many kinds of vulnerabilities which made them especially prone to the manipulation O’Neill describes. My own view is that when enough factors are present to be persuaded that the capacity for rational decision-making is comprised in ways that have significant consequences, something like a reasonableness standard needs to be applied. That is, when pain, depression, or other motivationally relevant factors are present to the extent that they fundamentally hijack the reasoning processes we can and should do what a ‘reasonable person’ would want under the conditions of the patient in question.
O’Neill’s point seems to be this. “What we have are patterns of reasoning which yield different answers for different patients and for different proposals for treatment.” (page 58) It is hard not to agree with this observation and hard not to say something like, “obviously…” As I wrote in the beginning, I think that how medicine proceeds in the real world is already something like what O’Neill writes about here.
I have no quarrel with the list of types of partial autonomy O’Neill writes about in her final section. They seem to me to represent bona fide differences in situations which require commensurate differences strategies to reach that point I described earlier where one is satisfied one has not simply run rough shod over a person’s wishes while nevertheless bringing to bear arguments and persuasion proportionate to the consequences of a “bad” choice.”