Progress in medicine: autonomy, oughtonomy and nudging

Abstract

In this article, I argue that we need a new perspective in the debate on autonomy in medicine, to understand many of the problems we face today - dilemmas that are situated at the intersection of autonomy and heteronomy, such as why well informed and autonomous people make unhealthy lifestyle choices. If people do not choose what they want, this is not simply caused by their lack of character or capability, but also by the fact that absolute autonomy is impossible; autonomous individuals are 'contaminated' by heteronymous aspects, by influences from 'outside'. Consequently, there are many good reasons to question the widely accepted hierarchical opposition of autonomy (progress) versus heteronomy (paternalism) in medicine. In an earlier article an analysis is made of the neologism 'oughtonomy' to support the thesis that when it comes down to human existence, autonomy and heteronomy are intertwined, rather than being merely opposites. In this article, I reflect upon how social conditions might improve our 'choice architecture', what Thaler & Sunstein have called 'nudging': how to change individual health choices without being paternalistic? I explore the extent to which both oughtonomy and nudging are able to challenge the question of autonomy in today's medicine. Autonomy may and should be a shared target in today's medicine, but we should never forget that it is always intertwined with heteronomy. Starting from this perspective, progress in medicine demands far more than the increase of autonomy.