Kant, autonomy and bioethics

Abstract

Summary The concept of autonomy has played a pivotal role in bioethics discourse since the 1970s. Yet, prior to the emergence of bioethics, autonomy had received scant mention in twentieth-century philosophy and was conspicuous by its absence from discussions of healthcare. The term was not even mentioned in the 1967 edition of the Encyclopedia of philosophy . The emergence of bioethics in the early 1970s coincided with increased attention across the western world to civil and human rights; with the rise of this new discipline the liberal emphasis on individual rights was recast in terms of respect for patient autonomy. Although its legal appeal was based on the ease with which autonomy was operationalized in the doctrine of informed consent, the power of the concept of autonomy lay in what it symbolized: the right of an individual to resist coercion or compulsion in the context of a relationship of power. Most commentators in the field of bioethics are familiar with autonomy as one of the four principles of biomedical ethics laid down by Beauchamp and Childress in their canonical text, The principles of biomedical ethics (1979) . ‘Principlism’ is a mid-level theoretical tool, which has had broad appeal in facilitating analysis of ethical dilemmas in biomedicine, grasped in the abstract as conflicts between two or more of the four principles. Yet the principle of autonomy, which has had such an extraordinary influence in contemporary bioethics bears only, passing resemblance to the concept of autonomy, which emerged in early modern philosophy. Although the bioethical redrawing of autonomy owes a large debt both to the philosophical tradition and to the social upheavals of the twentieth century, the relationship between contemporary interpretations of the concept of autonomy in bioethics and its historical origins is rarely examined. The purpose of this paper is to trace the evolution of the concept of autonomy from its emergence in modern moral theory to contemporary debates about its relevance for bioethical analysis. The roots of the principle of autonomy can be traced back to the political theory of ancient Greece. Originally used to describe the capacity of the Greek polis or city-state to govern itself, the concept of autonomy received its first modern expression – and its first application to the individual – in the moral theory of Immanuel Kant. For Kant, autonomy stood for the ideal of free will: a human will be driven to action, not by appetite or desire, but by identification with a ‘higher’ or rational self. At the heart of Kant's ethics is the close association of moral action with human rationality; for Kant, autonomous action – action which is deliberately and self-consciously motivated by moral reasons – is the quintessential expression of human rationality. Although the moral universalism Kant sought to defend is no longer philosophically tenable, his insights about many of the core features of autonomous action remained influential until well into the twentieth century. This paper falls into four parts: in the first section I will explore the contextual factors which influenced the emergence of autonomy as a principle appropriate for bioethical analysis. From there, I will examine the hugely influential definition of autonomy put forward by Beauchamp and Childress in the Principles of biomedical ethics and trace the philosophical foundations of this concept. I will then provide a brief account of the concept of autonomy so central to Kant's moral theory and I will conclude by examining recent accounts of personal autonomy in contemporary philosophy with the aim of arriving at a richer understanding of autonomy, which can perhaps be of greater service to bioethics.