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  • Writer's pictureRicky

Autonomy is Overrated

So now that I have a job in Bioethics, it’s time for me to figure out what Bioethics is.

Unfortunately, it looks like Bioethics is a huge mess, at least according to the Intro Bioethics Textbook I’m reading.

Actually, I’ve only read the first 13 pages of “The # 1 bioethics book on the market,” published by Oxford University Press, but alas, I have already been driven to despair.

Early on, we’re introduced to 5 Moral Principles of Bioethics:

  • Autonomy (”let people do them” is # 1?)

  • Nonmaleficence (don’t harm people)

  • Beneficence (help people...finally!)

  • Utility (to balance helping people and not harming them, you gotta Do The Math)

  • and finally there’s Justice, in part because Doing The Math keeps turning out to be exclusionary at best and eugenicsy at worst.

Today I’m mostly just going to complain about the first principle on this list, Autonomy, while I try to figure out how to express why this book frustrates me so much.

So let’s do a little close reading. Here’s our introduction to autonomy:

Autonomy refers to a person’s rational capacity for self-governance or self-determination—the ability to direct one’s own life and choose for oneself.

Sorry wait a minute, I gotta hold us up here.

Why are starting with autonomy and not something a bit more familiar like freedom?

Well because we’re shadowboxing Kant, but you may not even know who he is. So let’s back up.

Kant was was an incredibly ambitious system-builder who was (to his credit) unsystematic enough to break all his own rules when he had to, which was reasonably often. He’s probably the most influential philosopher since another Immanuel you may have heard of.

A lot of your ideas come from Kant or have been filtered through him. And even though Kant didn’t invent the word ‘autonomy’, his understanding of it has been very influential.

‘Autonomy’ is a 17th-century construction from the Greek:

autos ‘self’ + nomos ‘law’ = ‘self-law’

When I’m autonomous, I am the causal source of my own actions. In order to govern myself, I have to give myself my own laws in the right kinds of ways, as opposed to being acted upon by external forces in the wrong kinds of ways.

Wow Ricky that definition sure was handwavy.

You’re right!!

But Kant’s busy trying to make sure that humans are all equal and way more important than animals, a project that never seems to go very well once you drop the explicit appeal to souls. (Also he never left his German hometown so yeah he is pretty racist about, say, black humans.)

So here’s what he tries: What makes humans morally special & equal is our common rationality. Unlike animals who only act by instinct or whatever (again an 18th century German is just wrong nbd) I’m able to give myself laws, and so are you.

But since we’re both autonomous, there are certain moral constraints on which sorts of laws we can give ourselves to act from. For example, I shouldn’t give myself laws that couldn’t be universalized, which is a fancy way of saying something we tell kids all the time.

Oh, you want to steal your friend’s toys, or free-ride off of public goods without paying any taxes? Well, what if everyone did that? The whole system would collapse!

So you’re acting contrary to reason.

You can thank Kant for that hugely influential formulation of a very simple moral idea.

Okay so now that you know just a bit more about Kant and autonomy, we’re now ready for the next sentence:

The principle of autonomy insists on full respect for autonomy.

Yeah I don’t know what this means either. I guess autonomy toots its own horn?

One way to express the principle is: Autonomous persons should be allowed to exercise their capacity for self-determination.

So since we can give ourselves our own laws, we should be able to? I mean I don’t disagree, but I assume there are some reasonable limitations coming!

Just because something really comes from you doesn’t mean it’s good.

Moving on...

According to one major ethical tradition,

Say Kant you cowards! You already defined ‘descriptive ethics’, ‘normative ethics’, ‘applied ethics’, and ‘metaethics’ to make a huge trainwreck on the second page of this intro textbook, and you’ve even introduced W. D. Ross (???) the page before.

I’m so mad.

autonomous persons have intrinsic worth precisely because they have the power to make rational decisions and moral choices. They therefore must be treated with respect, which means not violating their autonomy by ignoring or thwarting their ability to choose their own paths and make their own judgments.

Okay, it sounds like autonomy is very, very important. But are there exceptions or limits on autonomy? If so, how do they work?!

Can I lie to the Nazi at the door who asks if I’m hiding any Jews? That would disrupt his life plan…but if I don’t lie, I’m definitely disrupting my Jewish friend’s life plan. And wait a minute, don’t I have a life plan going on here given that I’m faced with a choice at the door?

How are we going to resolve conflicts between the life plans of autonomous beings??

Hmm so far I have one unrestricted principle which is to let folks do them. Let’s see if we get any guidance for reigning this in:

The principle of respect for autonomy places severe restraints on what can be done to an autonomous person. There are exceptions, but in general we are not permitted to violate people’s autonomy just because we disagree with their decisions, or because society might benefit, or because the violation is for their own good.

Okay, so what are the exceptions?

We cannot legitimately impair someone’s autonomy without strong justification for doing so.

Right, what would strong justification look like??

Conducting medical experiments on patients without their consent, treating competent patients against their will, physically restraining or confining patients for no medical reason—such practices constitute obvious violations of personal autonomy.

Okay so these cases are obviously wrong. But why?! Again, what would a strongly justified exception look like, where the value of autonomy is overcome by other considerations, and how does that process work?

New paragraph:

Not all restrictions on autonomy, however, are of the physical kind…

And we’re off to the races to talk about something else. The text is excited to introduce the importance of informed consent and the dangers of paternalism, and that’s all great stuff.

But I don’t trust this broader argumentative strategy:

  1. Look at these cases where autonomy is completely trampled

  2. Wow they’re obviously really bad

  3. Therefore, autonomy is super important

Well, is it autonomy that’s important? Lots of things are getting trampled in these cases!

For example, if you confine patients for no medical reason, you restrict their happiness, their freedom, their ability to go on walks

So why isn’t the ability to go on walks the first principle of Bioethics?

Without any real interrogation into why autonomy’s good, or why autonomy’s # 1 instead of, say, freedom (I’ll be more charitable), we aren’t making any real progress articulating our own moral experiences and commitments. We’re just patting ourselves on the back for the intuitions we already have, ya know, wherever they come from.

But as I’ve tried to show by giving just a glimpse into the history of how autonomy gets developed and articulated, autonomy is a really weird concept with its own agenda.

Kant uses autonomy to try to show why humans = humans > animals. But using autonomy for this job comes with its own costs. By valuing autonomy, we commit ourselves to trying to disentangle every aspect of how we direct our own lives and choose for ourselves:

Do I like pizza because of me? Or because of my culture? (Is my culture internal or external to me?)

How much of my desire for pizza causally results from a lifetime of watching melty cheese pizza ads? Ads are a big part of my culture, and I hate them. (But why do I hate ads? Is it because my culture implicitly treats them as the price to be paid for accessing “content”…?)

Autonomy fetishizes causal independence, the idea that I am the causal source of my choices and judgments. But am I the causal source of my desire for a slice of pizza or not?!

Deciding that is gonna be a huge mess that gets into philosophical puzzles about free will and causation and moral responsibility. But until we figure out answers to all these technical questions, we don’t really understand the metaphysical building blocks of moral reality. Oh no!

Thesis statement:

Autonomy fetishizes Causal Independence. Even if X really was “purely” caused by me, why would that make it better?

I’m much more interested in freedom, which Isaiah Berlin helpfully divides into two main kinds:

  • Negative freedom is about lacking obstacles. I’m not free if I’m stuck in a room against my will. Negative freedom says: leave me the hell alone.

  • Positive freedom is about having prerequisites. I’m not free if I’m denied my basic needs like education or food or clean air. Positive freedom says: support me adequately.

Positive freedom is sort of like autonomy, but it’s less invested in metaphysical puzzles about causal independence and more concerned with something like the following question:

What does it take for us to grow and mature as agents?

And that’s a very different question. I will never become fully causally independent (whatever that means) because my actions affect the world, which in turn affects me. But I can grow and mature as an agent. And that’s much less mysterious.

These are the problems we face when raising children and going to therapy. We have lots of resources for growing and maturing as agents, and overall, we agree on some pretty clear standards of what progress looks like.

I think that by centering autonomy, bioethicists are really misdescribing their own views about what’s important. I think we mostly care about various kinds of freedom, and autonomy is just a concept with a long history that’s in the same neighborhood.

So maybe my work as a bioethicist is to help folks historically situate their own moral vocabulary and then rearticulate their own moral commitments a bit more carefully.

For you three Nietzsche fans: Oh my God I’m not the only genealogical bioethicist in the world am I?

Well if I am, at least my job is safe.

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