Commentary: Autonomy revisited – a response to H. Haker
Ethics Symposium Part I: Should ideology be allowed to trump patient well-being?
Alastair V. Campbell, Chen Su Lan Centennial Professor in Medical Ethics, National University of Singapore.
(fax: (65) 6778 9527; e-mail: email@example.com).
The (appropriately) provocative title of this group of papers – ‘Should Ideology be Allowed to Trump Patient Wellbeing?’ – immediately raises associations with recent gross abuses of medicine: for example, the use of psychiatric institutions in the USSR under Stalin to detain political dissidents; or the complicity of the medical profession in Apartheid South Africa in the torture and murder of the human rights campaigner, Steve Biko (and many others); or, perhaps most obviously, the powerfully influential eugenic philosophy in both Europe and the USA early last century, which led to the atrocities of the Nazi era in Germany.
However, this title also invites critique of a rather different ideology in medicine – that of the new medical ethics that has influenced medical practice, at least in the West, since the 1960s. It suggests that our claim to be acting ethically may in fact be poorly concealed imposition of an inappropriate ideology, which is to the detriment of patients. (This seems like a kind of commentary on what T.S. Eliot, in Murder in the Cathedral, describes as ‘the greatest treason’–‘To do the right deed for the wrong reason.’ )
Invited to make this kind of critique of modern medical ethics, Haker has singled out respect for the autonomy of patients as the chief culprit . This may not be the only example of an ideological bias in modern medical ethics (another might be the favouring of ‘rescue medicine’ over long-term care, with its attendant denial of both morbidity and mortality), but I do agree that we need to look very carefully at both the interpretation and the practical applications of the concept of autonomy. Thus, my response to Haker will not be negatively critical of her main conclusions . Instead, I will amplify two aspects her argument. First, I shall suggest that we can understand the concept of autonomy in a way that aligns it with concerns for justice and with concepts of the good society; and secondly, in the light of the fact that I now work in Asia, I shall explore the question of plurality in values in relation to the debate about ‘Asian Bioethics’.
Autonomy and Individualism
A frequent confusion in uses of the term autonomy is to conflate it with the idea of self-sufficiency or independence. A shorthand way of describing this error is that autos (self) has engulfed nomos (law). A correct understanding of moral autonomy, I would argue, describes a regulated life in the company of others, not the randomness and potential chaos of acting as one chooses at any given moment. This error is compounded by supposing that we can act in total isolation from others, rather than recognizing the fundamental relatedness and dependency of human existence. I have tried in an earlier publication to stress the interrelatedness of human life:
To be a creature is to be born of others, to know ourselves through them, to depend on them and create dependency, to know the pain of losing them and finally to be the instance of that pain to others. 
If we leave this kind of naïve individualism unquestioned, we quickly erode the basis of morality itself, because this surely depends on reciprocal rights and obligations between ourselves and others (as Haker notes in her paper ).
To expand on this point, I turn to Onora O’Neill’s Gifford Lectures, Autonomy and Trust in Bioethics. O’Neill offers an exposition of Kant’s approach to morality in terms of principled autonomy. She writes:
[Kant] does not see autonomy as something that some individuals have to a greater and others to a lesser degree, and he does not equate it with any distinctive form of personal independence or self-expression, let alone with acting on some rather than other sorts of preferences. Kantian autonomy is manifested in a life in which duties are met, in which there is respect for others and their rights, rather than a life liberated from all bonds. 
Understood in this way, autonomy is not in any real tension with justice. On the contrary, autonomy is exercised only through acting justly. This means that respect for autonomy in medical ethics must mean respect for patients as moral agents, who are capable of taking responsible choices out of consideration for the needs and rights of others, as well as their own needs and wants. Such a view of autonomy casts some of the problems mentioned by Haker in different light . It could mean helping the teenager in her example to resist the current image of feminine worth as having big breasts, and it could give greater authority to the notion of community well-being, contained in the microbicide trial example. At the very least, it provides some resistance to the current notion that patient autonomy should be equated with consumer satisfaction.
Of course, there are hazards in this approach – most obviously that such an emphasis on an autonomy based on principles can provide an apparent justification for authoritarianism of all kinds, including the closed and repressive societies created by religious fundamentalism. It is notoriously difficult to reach a consensus on the ‘good society’, and although Kant believed that his principle of universalizability would ensure fairness to and respect for all, the historical reality is that arbiters of what is right frequently use the concept of the moral law to repress freedom of thought and belief. A second criticism of such a thick concept of autonomy is that it sets too high a standard, asking more of people than is reasonable to expect in their freedom to choose. Thus, principled autonomy could be seen as supererogatory – an aspiration rather than a universal obligation on moral agents. Yet, despite these hazards, I believe that a richer form of autonomy is worth pursuing, and so I turn to the second part of my response: the enriching potential of cultural diversity in ethics.
The debate about Asian Bioethics
Can a pluralistic approach to bioethics offer a way round the uncertainties in understanding autonomy appropriately? I am approaching this question by considering the claim that Eastern approaches to Bioethics are significantly different from the individualism of the West. Debate about this fundamental question has gone on for at least 10 years and has produced several edited volumes [5–8].
Let us start with a broadside against ‘the Specious Idea of an Asian Bioethics’, recently published by a Chinese bioethicist, working in New Zealand, Jing-Bao Nie.  Nie criticizes the tendency to stereotype Asian Bioethics as communitarian, collective or familistic, contrasting this with a Western liberal emphasis on individual rights and freedoms. He points out that the cultural differences between Asia and the West are far more ‘complicated, subtle, fascinating [and] difficult to discern’ than such a simplified contrast. On a similar note, Ren-Zong Qiu, in the introductory essay to his edited volume, reminds us of the huge cultural and religious diversity of Asia: ‘In Asia there are Confucian, Taoist, Buddhist, Hindu, Islamic, Christian and many native cultures’. He concludes that the moral diversity of Asia should be recognized and welcomed. Jing-Bao Nie and I, in a recent editorial, have sought to make the same point . We argue that Asia presents a supreme example of multiculturalism, one which has a history stretching back over centuries. This feature of Asia has a potential for good or for ill. It may result in aggressive nationalism, attempts at theocratic states, and cultural war – and sometimes actual war – as one culture seeks to dominate the others. But multiculturalism may also offer us a richer understanding of the moral universe than any single culture can achieve.
Perhaps, then, what we need to do is abandon the notion of ‘Asian Bioethics’, as although this was some distinct and easily described entity. Instead, we should discuss what might be important features of ‘Bioethics in Asia’. This would suggest that we are dealing with the same discipline, but that the Asian context can add new dimensions, raise new questions or help to shift perspectives.
I feel that already in Asia, there is a growing body of literature that does provide such conceptual shifts. The best examples of this are to be found in current attempts to reconstruct Confucianism. One such is the exposition by Ruiping Fan in the volume edited by Qiu . Fan argues that it is possible to reconstruct traditional Confucian teaching in a way that avoids common criticisms of it as paternalistic, sexist and hierarchical. By basing morality on the foundation of the intimate tie between parent and child and by respecting the order implicit in the caring nexus of the family, an alternative to individualistic rights-based bioethics can be constructed. In this alternative to rights claims, there is a powerful respect for virtue, and instead of equality being the fundamental ethical norm, reciprocity of needs and duties forms the basis for all moral relationships, extending outwards from the family. Julia Tao, in an article in the same volume, offers a different ‘take’ on what Confucianism has to offer. She calls it ‘relational autonomy’, a view that she thinks harmonizes Confucianism with feminist theory. She sums up her view as follows:
A Confucian or feminist approach to bioethics reminds us that the value of the human agent is not grounded in rationality or autonomous choice-making alone, but in meaningful relationships of interdependency and human interaction. 
My conclusion, then, is that medical ethics could well not be in the best interests of patients. The critical question is whether we can get past a somewhat impoverished concept of autonomy to one which does justice to the complexity of human relationships and to the mutual responsibilities we all share in. Perhaps, allowing cultural diversity to enrich our moral understanding will help in this, but in all honesty, we have to say that medical ethics has still got a long way to go in recognizing and promoting the subtle interdependencies of the moral life.
Conflict of interest statement
No conflict of interest was declared.