Introduction to autonomy theory
To be autonomous is to be self-governing. In this text, I introduce the concept of personal autonomy as it is generally understood in bioethics. Two theories of autonomy are explained in brief terms, namely Juth’s and Beauchamp and Childress’s. I think that the concept is fruitful also in political contexts, but I will leave it to the reader to consider its political applications.
TO BE AUTONOMOUS
The term autonomy comes from the ancient Greek auto, which means “self,” and nomos, which means “law.”1 Being autonomous means that one is self-governing. There are various autonomy-related concerns in bioethics. For instance, a patient who is about to undergo a medical procedure should be informed about how the procedure is likely to affect her person and her way of life. That is, it is important for moral reasons that the patient is autonomous with regards to her healthcare decisions.
It is generally held that autonomy, in the moral sense relevant to the present discussion, is a property that persons can enjoy. Nonpersons, such as very small children, animals, and inanimate objects cannot be autonomous in this sense. Autonomy can be enjoyed to different degrees, meaning that it is not a binary concept; a person can be more or less autonomous, as well as non-autonomous and fully autonomous. And, autonomy is a property with both positive and negative elements. Positively, autonomous persons are, for instance, capable of qualitative self-reflection; they can assess their own desires and values and choose whether to be moved by them. Negatively, autonomous persons are not subject to the control of other agents, influences, or conditions.
In contemporary theory, the distinction is often made between procedural and substantial accounts of autonomy. In the procedural tradition, personal autonomy only concerns the form that decisions and actions take. Theorists are here only interested in matters such as the process by which the agent comes to make a decision, the independence of her choosing relative to external influences, and so on.
In the substantial tradition, autonomy also concerns the content of decisions and actions. In addition to matters of a procedural nature, substantialists also take an interest in whether an agent’s choices are self-supporting. To demonstrate, consider a person who is physically and mentally abused by her partner. The victim reflects upon whether to leave her partner, but decides not to do so. When analyzing the case, proceduralists take into consideration the process by which the victim makes her decision, putting weight on the independence of her decision-making procedure. They may conclude that the victim made an autonomous choice. Substantialists, on the other hand, are concerned also with the fact that the victim chose not to leave her abusive partner. They may conclude that, as the victim’s choice is self-injurious rather than self-supporting, it is non-autonomous.
Proceduralists sometimes accuse substantialists for unjustified paternalism, who tend to reply that proceduralists unwarrantedly ignore the social embeddedness of persons. I will not engage in that debate here. In what continues, I will only discuss the procedural tradition, in line with mainstream Western bioethics.2
Finally, I prefer to distinguish between two types of procedural autonomy theories, namely ideal and non-ideal. There are many different usages of these terms (Valentini 2012). Here, I intend “ideal theory” to designate some model of autonomy that is largely hypothetical. Few or no persons or decisions are ever fully autonomous in this sense, as the conditions under which ideal autonomy obtains are perfect or conceptual. By “non-ideal theory,” I intend accounts that are not constructed accordingly. The approach is sometimes also known as “realist” or “problem-oriented,” as it starts from actual people, facts, conditions, etc., in the real world rather than in some theoretical model.
ONE IDEAL ACCOUNT OF AUTONOMY
One ideal account of autonomy is found in Juth (2005). Juth proposes a ”minimalistic definition” of autonomous persons as a point of departure: ”A person, in a situation, is autonomous to the extent that she does what she decides to do, because she decides to do it, and decides what she wants to do, because she wants to do it” (p. 137). There are three basic components in this account, namely authenticity, decision-competence, and efficiency. I will elaborate briefly on them here in that order.
To be authentic is to be ”genuine,” ”real,” ”true to oneself,” or similar. Juth proposes that authenticity should be understood as a pro-attitude towards one’s own desires in light of an explanation of why one has them (p. 153). He formulates this idea as: ”P’s desire X is authentic to the degree that P would have approved of her having X, if she had knowledge about why she has X” (Ibid). Likewise, a desire is inauthentic if the desire-holder would disapprove of having it upon informed and critical self-reflection.
To have decision-competence is to be able to rationally consider one’s options and choose in favor of one of them, or in Juth’s suggestion; the ability to ”decide what to do on the basis of one’s desires and beliefs” (p. 163). Among other things, this capability presupposes a minimum of imagination, so that one can picture the different alternative outcomes of one’s decision, and the ability to judge the alternatives one considers. This means that decision-competence also requires that one has an idea of one’s wishes, and that one can think critically about them (p. 164).
Finally, efficiency in this context is to be capable of implementing one’s decisions through action (p. 168). This means that one has the necessary powers to realize one’s desires, i.e., to achieve one’s goals through one’s own decisions and actions. Influences that affect efficiency may be both internal and external to the agent. For instance, drug addiction is an internal influence that may negate one’s power to realize one’s desires. One example of an external influence is coercion; if a person is coerced to do or not to do something, this has an influence on her efficiency.
To sum up, in Juth’s theory, a person is autonomous to the extent that she does what she decides to do because she decides to do it, and decides what she wants to do because she wants to do it. There are three basic components in this account, namely authenticity, decision-competence, and efficiency. Each has an effect on the degree of autonomy with which a person acts.
ONE NON-IDEAL ACCOUNT OF AUTONOMY
Beauchamp and Childress propose a non-ideal account of autonomy which builds from the premise that everyday choices of generally competent persons are autonomous (2013, p. 104). Autonomous actions are then analyzed “in terms of normal choosers who act (1) intentionally, (2) with understanding, and (3) without controlling influences that determine their action” (Ibid).
The premise that everyday choices of generally competent persons are autonomous includes standards of incompetence, i.e., conditions that negate a person’s decision-making capabilities. Examples of such conditions are an inability to express or communicate a preference or choice and an inability to understand one’s situation and its consequences (p. 118).
Beauchamp and Childress explicates the condition of intentional action by contrasting it with accidental action; intentional actions “correspond to the actor’s conception of the act in question,” whereas accidental actions do not (p. 104). Examples of accidental actions may include sneezing, blinking, and uncontrolled spasms.
The condition of understanding means that an act is non-autonomous if the agent does not adequately understand it (Ibid). Having an adequate understanding of an act means that one has a reasonable estimation of its nature, meaning, and outcome.
Finally, the third condition concerns acting without controlling influences (pp. 104–5). Controlling influences may be external to the agent, such as when she is coerced or manipulated into performing some act, or internal to her, such as when she is drunk or suffers from some mental disorder.
Thus, to summarize, Beauchamp and Childress build from the premise that everyday choices of generally competent persons are autonomous. Then, they introduce a set of factors that indicate that a person is non-autonomous, namely non-intentionality, non-understanding, and non-control. Together, they enable the judgment that someone is more or less autonomous with regards to their own decisions and acts.
To be autonomous is to be self-governing. In this text, I have introduced two theories of autonomy, one ideal and one non-ideal. Both include a focus on competence, so that autonomy is analyzed in terms of capabilities, but are different not least in that only Juth’s theory includes a condition of authenticity.
This text presents the mainstream theoretical approach to the concept of autonomy in bioethics. Although I think that the concept is fruitful also in political contexts, I leave considerations of its possible political applications to the reader.
1 This section builds on Ahlin (2017).
2 For further inquiry into the debate between proceduralists and substantialists, see, e.g., Christman (2004) and Oshana (2015).
Ahlin, J. (2017). Personal Autonomy and Informed Consent: Conceptual and Normative Analyses (licentiate thesis). KTH Royal Institute of Technology, Stockholm, Sweden.
Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics. Oxford University Press.
Christman, J. (2004). Relational Autonomy, Liberal Individualism, and the Social Constitution of Selves. Philosophical Studies 117(1), 143–164.
Juth, N. (2005). Genetic Information – Values and Rights. The Morality of Presymptomatic Genetic Testing (doctoral thesis). Acta Universitatis Gothoburgensis. Gothenburg, Sweden.
Oshana, M. A. L. (2015). Is Social-Relational Autonomy a Plausible Ideal? In Oshana, M. A. L. (Ed.). Personal Autonomy and Social Oppression: Philosophical Perspectives (pp. 3–24). Routledge.
Valentini, L. (2012). Ideal vs. Non-ideal Theory: A Conceptual Map. Philosophy Compass 7:9, pp. 654–664.
Cite as: Ahlin Marceta, J. (2018). Introduction to autonomy theory. Retrieved (date) from: https://jahlinmarceta.com/for-students/introduction-to-autonomy-theory/