Can the Moral Commons Survive Autonomy?

Abstract

Perhaps nothing has so exasperated me over the years as the deference given in bioethics to the principle of autonomy. To be sure, those who espouse the moral theory of principlism have always insisted that autonomy is only one among other important principles (that is, justice, beneficence, nonmaleficence), always to, be balanced against them. But my own observation is that autonomy has had far and away a pride of place in practice. Justice has given it some competition, but most contemporary theories of justice (for example, Rawls) have an individualistic point of departure anyway; and most renderings of beneficence have had about them the flavor of religion or goody-goodiness, sure losers in the secular world of public policy. Now, no one in our society, including me, wants to say that individual liberty is not a high value. I prize it and so should everyone else. It is the cornerstone of our laws, many of our valuable customs, and a necessary ingredient of any viable theory of human rights. Given that background, it is perfectly understandable that American bioethics should pick up autonomy and run with iL What is less understandable, more disturbing, is the preemptive role it too often has come to play, and with that a distressing exclusionary function. It is not just what autonomy lets in that is the problem, but what it pushes out, whether inadvertently or not. I locate the main problem in what I take to be the working public policy axiom of autonomy. if someone wants something, and no direct harm can be shown to result, then he or she should be allowed to have it. Since it is usually easier to identify benefits than harms, particularly long-term harms, autonomy is thus able easily to preempt the high ground. Moreover, because of the cultural power of autonomy there is often little incentive to look hard for possible harms or, even if some can be identified, to let them take precedence. Every benefit of every doubt is given to autonomy. Although it has very different historical origins, the idea of individual patient benefit often works together with autonomy to play an exclusionary role: that of ruling out population benefits and harms in making clinical decisions. I offer two cases. One is artificial reproduction. In that case, whether it be artificial insemination or egg donation or surrogate motherhood, the autonomy of the would-be parent has de facto triumphed over all moral objections. It has been hard to prove long-term harm - which we will have to experience first to have it count - and even harder to make the case that those possible harms should override individual choice. I believe that the first wrong step in artificial reproduction, taken years ago, was the acceptance of anonymous sperm donations. To me that is a way of downgrading fatherhood and of violating a basic moral principle; through sperm donation a man is allowed to become a biological father but is not held responsible for the consequences of his act. What odds would the bookies in Las Vegas give on the likelihood I can successfully make that case in our society (or even among most of my bioethical colleagues)? My second case is resource allocation. There is now perfectly solid evidence that the best way to improve population health is through public health measures, including health promotion and disease prevention. There is no less solid evidence from the experience of the European countries that the best way to hold down health care costs is to have global budgeting and tight controls on the use of technology. But in our country so powerful is the claim of autonomy and liberty that we are reluctant to use the power of the state to improve public health (smoking is the one exception here). And whenever there is any talk of controlling costs by means of social policy, the prevailing counterargument is always that, in line with American individualism and the Hippocratic tradition, only individual benefit should count in making medical decisions. …