Promotion of Autonomy as a Goal of Medicine Prospects and Problems Christian Munthe Department of Philosophy, Gothenburg University

The Goals of Medicine: n Positive values n Define what makes health care better – towards what ends medicine should strive. n Basis for determination of what medical procedures to offer, in what form, mode of distribution, etc. n Complemented by ethical restrictions. n Traditional candidates (not so controversial): u Relieving of suffering (promotion of well-being) u Prolongation of life (prevention of death)

New Candidate: Promotion of Autonomy n Reason of emergence: u Medical procedures that are in demand but cannot be shown to promote traditional goals n Typical areas of use (so far): u Genetic testing u Assisted reproduction u Public health medicine n Ideological roots: u Traditional ethical restriction to respect autonomy u Consequentialist models of ’goal theories’ n I.e.: an ’unholy union’, smelling of ad hoc… n …that may nevertheless be defensible!

Basics of the Idea n Autonomy is a matter of degree: u P is autonomous to the degree that P’s life at its various stages is in accordance with P’s basic wants/desires/plans at these stages. n Degree of autonomy is a determinant of ’well-being’: u Ceteris paribus, the more autonomous is P, the better is P’s life, and the less autonomous is P, the worse is P’s life. n Can conflict with other such determinants. n Can be aggregated and compared over indivuals. n Not to be confused with ”preferentialism”. u Only ’now-for-now’ and ’then-for-then’ preferences u Only ’basic’ wants u No requirement of information, rationality etc. n Can be the subject of variable normative restrictions and/or recommendations.

Why even consider it? n Surrender to reality…(???) n Basic moral–axiological intuition: u At least a part of the good life is to lack reason to complain about it through its various shifts. u Frustration of basic wants is a reason for complaint. n The ’priority of liberty’ type of argument: u When sufficient material welfare is secured, the ability to determine one’s own destiny becomes a priority. u The more health care masters acute threats to life and limb, the more important it becomes to gain control of the life thus gained. n The argument from respect-theories: u If we have reason to refrain from restricting autonomy, we have at least some reason to promote autonomy. u Not to promote autonomy is morally equivalent to restricting it. u Denying the moral relevance of the doing-allowing distinction.

Theoretical Problems n The ’metric’ of degrees of autonomy u Is it construable? (YES! The problem is normative, not technical) u Can a normatively satisfying metric justify sufficiently precise interpersonal comparisons? n What weight should be given to autonomy as compared to other goals of medicine? u Life – autonomy u Well-being – autonomy u Intrapersonal – interpersonal u The goal structure of medicine might ’turn organic’. u A battery of ’hard cases’ needed for further thought. n If autonomy promotions can be traded off against other values, can the restriction to respect autonomy still be rigidly upheld?

Practical Problems 1 Metrics and comparisons once more n Giving autonomy a place in quality of life u Must give autonomy a place in QUALY-type measures. u Must give autonomy a place in cost-effectiveness measures. u Must give autonomy a place in prioritarization schemes. n Normative puzzles u ’How many pounds of silver for an ounce of autonomy?’ u How resolve interpersonal autonomy conflicts? n If the goal structure ’turns organic’, practical problems multiply. n But autonomy is no carte blanche for distribution according to demand.

Practical Problems 2 What becomes of professional responsibility? n People’s wants are expressed in health care demand u Demand may be a reason for offering a procedure. u Demand may tip the scale so that risks are balanced by sufficient potential benefits. u Procedures that would otherwise have been considered irresponsible to offer, suddenly becomes responsible n Can health care professionals still be justified to resist the offering of procedures in demand? n Can autonomy be a reason for resisting meeting a demand? n Autonomous life ≠ a life filled with free choice n Still unclear in what situations we have good reason for restricting free choice for the sake of autonomy.