Introduction

The introduction outlines the motivation for investigating the relationship between autonomy and rationality in contemporary bioethics, and maps the contours of a pre-theoretical understanding of autonomy, in preparation for the theoretical analysis to come. Having noted some apparent ambiguities and tensions within the widely accepted assumption that there is a close relationship between autonomy and rationality, the author briefly distinguishes procedural and substantive accounts of autonomy, and identifies Beauchamp and Childress’ pioneering work in the principles of biomedical ethics as providing the standard account of autonomy in bioethics. He outlines some objections to the standard account, and goes on to outline a framework that is used in the rest of the book for developing a rationalist account of autonomy that aims to avoid these objections.

Rational Decision-Making Capacity in End of Life Decision-Making

This chapter brings the rationalist account of decision-making capacity to bear on three case studies. The first concerns a patient who ‘unwisely’ refuses treatment for a condition that can be treated straightforwardly, but which will otherwise be fatal. The second concerns a Jehovah’s Witness who refuses a life-saving blood transfusion. The third concerns an individual suffering from anorexia nervosa, who recognizes that she is dangerously underweight, but who nonetheless refuses to consume food. The author argues that a rationalist approach can accommodate the thought that an individual’s decision-making capacity is not precluded by their making an ‘unwise’ decision. It can also accommodate both the thought that Jehovah’s Witnesses can have decision-making capacity to refuse blood transfusions, and that some sufferers of anorexia nervosa may lack decision-making capacity. The author argues that his account is better equipped to investigate the nuances of these hard cases than the standard account.

Controlling Influences

Drawing on the rationalist account of autonomy outlined in the previous chapter, this chapter provides a framework for identifying different forms of influence on individual decision-making. The author explains how his theory allows for a broader understanding of rational persuasion than that which is suggested by the standard account, and shows how different forms of persuasion can be compatible with autonomous decision-making. Such persuasion can be contrasted with psychological manipulation, which serves to directly alter an individual’s motivational states in a manner that bypasses the cognitive element of the target’s decisional autonomy. Having identified the various forms that psychological manipulation can take, the author argues that global forms of manipulation, which involve wholesale changes to an individual’s psychological economy, raise concerns about identity and responsibility but not autonomy. Finally, he outlines the implications of his theory for informational manipulation and deception.

Rationality and Decisional Autonomy

This chapter explains the role that theoretical and practical rationality play in decisional autonomy. The author contrasts his rationalist approach with other prominent rationalist theories of autonomy in bioethics developed by Rebecca Walker and Julian Savulescu. He suggests that one way in which both of these theories fall short is that they fail to offer a deep explanation of why we should trust that our evaluative judgements are the seat of autonomous decision-making. In order to provide such an explanation, in the second half of the chapter, the author situates his rationalist account in the literature on the philosophy of action. The discussion suggests that coherence theories of personal autonomy can offer this kind of explanation, and argues that supplementing such theories with considerations of theoretical rationality and an objectivist account of reasons can help to forestall some objections to such an approach.

The Practical Dimension of Autonomy

In bioethical discussions, the concept of autonomy is understood to incorporate a practical dimension, pertaining to an agent’s ability to act in pursuit of their autonomously chosen ends. Having defended the inclusion of this dimension of autonomy in one’s overall theory, the author outlines the different kinds of freedom at the point of action that may be necessary for practical autonomy, and how these can be socially mediated. He goes on to outline a modal test that can be used to identify whether a particular freedom is necessary for practical autonomy, and suggests that it can also be used to identify certain beliefs that a person must hold in order to be autonomous with respect to their decision. The chapter concludes by considering the implications that an agent’s freedoms at the point of decision may have for their decisional autonomy, and what bearing this has for the development and enhancement of autonomy.

Rational Autonomy and Decision-Making Capacity

Rationalist accounts of autonomy are often criticized on the basis of anti-paternalist concerns: If only rational decisions can be autonomous, one might worry that eccentric decisions may not be respected, and that more people would be found to lack decision-making capacity. The main aim of this chapter is to show how a rationalist approach can respond to the various ways in which such anti-paternalist concerns can be raised. The author first outlines some prominent accounts of decision-making capacity in the law and clinical literature, and claims that the widely adopted sliding-scale view of capacity need not fall foul of anti-paternalistic concerns. He then defends a rationalist approach to understanding decision-making capacity in ideal contexts from anti-paternalist concerns. The author concludes by responding to an epistemic version of the anti-paternalist objection in non-ideal contexts, according to which incorporating considerations of rationality into assessments of decision-making capacity would make costly errors in this assessment more likely.

Concluding Remarks

In the introduction to this book, I outlined my intention to provide an account of personal autonomy that can usefully be applied to issues in contemporary bioethics, and that clarifies its ambiguous relationship with rationality. At the most fundamental level, I understood the concept of autonomy to denote a particular capacity to which we seem to attribute prudential value in bioethical contexts, namely, a capacity that we invoke to capture concerns pertaining to an agent’s ability to both:...

Coercion

This chapter considers two questions: First, in what sense does coercion undermine voluntariness, and second, can offers be coercive? The second is particularly relevant in bioethics, as there are a number of practical debates in which it is claimed that vulnerable individuals’ autonomy is undermined by their being subject to ‘coercive offers’. Having adverted to cases of this, the author draws on the philosophical literature on the nature of coercion to answer the two aforementioned questions. He argues that our answers to these questions are importantly interrelated, and that this point has been obscured by a widespread misunderstanding of the difference between threats and offers. He then provides an account that accommodates the possibility of some coercive offers, and that also identifies features that are central to establishing whether an offer can serve to undermine voluntariness in a manner that is sufficient to invalidate consent.

The Prudential Value of Autonomy

The principle of respect for autonomy is undeniably afforded particular salience in Western bioethics. At least part of the reason for this is that autonomy is often understood to have a central role in the good life. In this chapter, the author argues that autonomy does not have merely instrumental prudential value; instead, autonomy is at least partly constitutive of well-being, since there is a special value in living a life that is one’s own. He defends a well-known argument that speaks in favour of this conclusion, before going on to consider the value of different elements of autonomy, according to the framework adopted in this book. The author concludes by assessing how autonomy can conflict with other central values in bioethics, and how the claim that autonomy has significant prudential value has important implications for how we should understand the concept of beneficence in bioethics.

Four Distinctions Concerning Rationality

Disagreements about the plausibility of rationalist autonomy in bioethics are often attributable to misunderstandings about the nature of rationality. So, it is imperative to be clear about the understanding of rationality that one is invoking in one’s account of autonomy. This chapter makes some first steps in this regard, by drawing four key distinctions concerning the nature of rationality. The first, between theoretical and practical rationality, concerns the different norms of rationality governing beliefs and desires. The second, between real and apparent reasons, concerns whether our beliefs about our practical reasons map onto reason-giving facts that actually obtain. The third, between objectivism and subjectivism, concerns the fundamental source of our practical reasons. The fourth, between personal and impersonal reasons, concerns the different kinds of facts that can ground practical reasons. In outlining these distinctions, the author follows Derek Parfit in endorsing an objectivist account of reasons.