Autonomy: what a useless idea!

Michael Cook
May 5, 2017
Reproduced with Permission

If I ask why abortion is legal, I will be told that women have a right to autonomy over their bodies. If I ask why same-sex marriage is legal, the US Supreme Court tells me that "the right to personal choice regarding marriage is inherent in the concept of individual autonomy". If I ask why minors should be supported in a quest to change their gender, I will be told that they are being courageous in exercising their autonomy. And if I ask why patients should be free to request euthanasia and why doctors should be forced to grant this request, I will be told that the answer is autonomy.

The concept of autonomy, and its cousins "choice" and "informed consent", capture part of what is distinctive about humanity. A rock cannot choose to move; an oak tree cannot opt out of photosynthesis; a cow cannot go on a hunger strike. We still have not found a chimpanzee which has requested euthanasia. So autonomy expresses a portion of what is real and valuable about being human.

But not everything.

Rather than waving autonomy as a talisman to avert the evil eye of conventional morality, we should be asking ourselves why it has become a trump card in all debates, from talk-back radio to Supreme Court decisions? Can it really justify this avalanche of changes in social policy? Is it a clear, coherent, incontestable concept?

The Supreme Court of Canada assumed so in in 2015 in Carter v Canada , the case which effectively legalised euthanasia and has become a touchstone for debating euthanasia in the English-speaking world. The judges concluded that banning euthanasia was inconsistent with Canadians' human rights:

An individual's response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy ... By denying them the opportunity to make that choice [of physician-assisted dying], the prohibition impinges on their liberty and security of the person. As noted above, s. 7 recognizes the value of life, but it also honours the role that autonomy and dignity play at the end of that life.

The Court's decision often pairs "dignity" with "autonomy", as if the judges were not completely sure whether autonomy alone were sufficient to justify euthanasia and wanted to have a two-way bet. A 2011 report to the Royal Society of Canada by several leading bioethicists was more straightforward: autonomy alone was enough. "The concept of human dignity is an unsuitable tool" for settling end-of-life questions. It is imprecise, vague, and tainted by its association with Christian theology.

But let's do some thought experiments about euthanasia. Can autonomy really do the heavy lifting of overcoming the uneasiness that we feel when a person asks to be killed? Bear in mind that Canada's euthanasia legislation only requires that a person be over 18, have a grievous and irremediable medical condition, and make a voluntary request. He or she is not required to be terminally ill or to be free of mental illness.

Nelson is 55-years-old CEO of an IT company. He has Crohn's disease, which is grievous and irremediable, but not necessarily fatal. Having married late, he and his wife have five children under 12. After serious losses on the share market, he asks for euthanasia, alleging that he is tired of coping with Crohn's. Without him, five children grow up without a father and his company will fail, leaving 50 unemployed.

Something within us whispers that Nelson's decision is wrong. He is responsible for too many people. Who knows how many of them will suffer lasting pain as a result of his decision to retire early from life? By itself, autonomy frames a patient as an individual whose death will not make others suffer. This is simply false.

Miriam is 85 but sprightly and active, although she does have a heart condition which slows her down and which will eventually kill her. Her three ne'er-do-well children, however, make it very clear that they are looking forward to enjoying her substantial assets. Wearied of their greed, Miriam asks for euthanasia. She is sound of mind and her request is voluntary. She insists that there has been no undue pressure.

Something within us whispers that this is a failure of justice, not of autonomy. Why should Miriam be regarded merely as an obstacle to someone else's profit?

Peter is a 62-year-old with Asperger's syndrome and prostate cancer. He is divorced, estranged from his children, friendless, unemployed, and desperately lonely. He asks for euthanasia.

Something within us whispers that society has failed Peter. If he had better psychiatric care and a more competent social worker, he might recover his interest in living. Isn't it worthwhile trying?

Deirdre is 58 and has breast cancer. She asks Alan, her family doctor, for euthanasia, although specialists have told her that her chances of living for another 20 years are better than 60 percent. Alan refuses her request and refuses to refer her to a more compliant physician, thereby risking the loss of his licence to practice medicine.

Something within us asks why Deirdre's autonomy is deemed to be more important than Alan's. Why should he respect her decision, even though it seems impulsive, emotional and disproportionate? Why shouldn't society respect his autonomy if it has been reached after much thought and is based on sound medical knowledge? On what basis do we decide who wins?

Realistic scenarios? Perhaps not. But they demonstrate that looking at end-of-life requests only through the lens of autonomy is deficient. Even if we cannot articulate our objections, our intuition suggests that this kind of moral reasoning leads to contradiction and incoherence. When we invoke autonomy in this way, we use it as an ideology rather than as a rational principle.

Futhermore, as professional philosophers acknowledge - in university seminars, that is, not in public debate - autonomy is a concept which is no less fiercely contested than "human dignity". In fact, there seem to be as many different accounts of autonomy as there are philosophers, all of them trying to distinguish between external pressure and authentic personal choices. The philosopher Sarah Buss admits in her discussion of autonomy, "As the number and variety of these accounts indicate, the distinction is extremely elusive."

The influential Royal Society of Canada report insists that "individual autonomy" is "paramount" in personal decision-making and absolutely central to the existence of liberal democracies. Yet it also concedes that "There are many conceptions of autonomy" and that "The ethical stakes involved in selecting a particular conception of autonomy are considerable". With this diversity of viewpoints, how practical is it for a doctor without a PhD in philosophy to discern which of these conceptions justifies giving his patient a lethal injection?

Furthermore, the philosopher who practically invented the idea of autonomy as the distinguishing element in human dignity, Emmanuel Kant (1724-1804), insisted that suicide (and presumably euthanasia) could never be justified. "Suicide is in no circumstances permissible" and "Nothing more terrible can be imagined" he wrote in The Metaphysics of Morals. The suicide, he asserted, "robs himself of his person. This is contrary to the highest duty we have towards ourselves, for it annuls the conditions of all other duties." In other words, how is a person truly exercising autonomy when he deprives himself of the possibility of acting autonomously? Since Kant is probably the most important philosopher of the last 200 years, it seems fatuous to dismiss his intuitions as not "meriting too much attention". But autonomistas have no hesitation in doing so.

None of these remarks show that euthanasia is wrong. But if it is right, there must be more and better reasons than autonomy to justify it. As employed nowadays in public debates, autonomy has become little more than an ideological trump card which obliterates opposition by virtue of religious deference rather than rational coherence.