What is Consent? How do we

Respect Autonomy?Week 3: The Evolution of Bioethics: Autonomy and

Informed Consent

Consent and Autonomy

• Autonomy is the philosophical underpinning

and justification for the Doctrine of Informed

Consent– But what is Autonomy?

– Literally means: Self-Rule (Auto-Nomos)

• Possible cases of autonomous action

– Choosing what to have for breakfast in the morning

– Refusing a blood transfusion due to the dictates of the

religion you were raised in

– Choosing to have a cigarette while being a life-long smoker

– Choosing to give up your wallet to someone who has held

you up at gunpoint

Choosing to Deliberating?

Choice Theories: A person is autonomous (or their action was autonomous)

if they chose between options and carried out the one they chose.

Deliberative Theories: A person is autonomous (or their action was

autonomous) if they were able to properly carry out a deliberation about

which choice to make. [Actual action in accord with the deliberation may not

be necessary]

Choosing to Deliberating?

Choice Theories: A person is autonomous (or their action was autonomous)

if they chose between options and carried out the one they chose.

Deliberative Theories: A person is autonomous (or their action was

autonomous) if they were able to properly carry out a deliberation about

which choice to make. [Actual action in accord with the deliberation may not

be necessary]

The Doctrine of Informed Consent includes both

deliberative and choice elements

What is Involved in Deliberation?

• Ideally, deliberations occur with full

knowledge and full rationality

– Not actually possible

• A person is more or less autonomous to the

extent that their deliberations come closer to

or further from Ideal Deliberation

Evaluating Autonomy

• A paranoid schizophrenic has many false beliefs, and also often

reasons improperly even given those false beliefs

– This person, by most estimations, is not autonomous when he or

she is in the grips of his or her delusions

• Linda, and many other people with certain mental

illnesses, often have false beliefs, but may reason quite well

given those false beliefs. Or their belief set may not be any

more plagued by false beliefs than most other people‟s, but

they reason improperly.

– These people are still considered by many to not be autonomous

• “You and me” – We likely have many false beliefs and

many unjustified beliefs, and we regularly reason

improperly

True Beliefs

True beliefs tell us what options are like, so that when we choose from

among them, we are truly choosing

JWs refuse blood transfusions due to a particular interpretation of scripture.

-Savulescu says such a false belief arises out of theoretical irrationality - A

failure to deliberate properly.

So, if true beliefs are necessary for autonomous choice, and all of us have at

least some false beliefs which likely, at some point, influence our medical

decisions, then are any of us ever really giving informed consent?

Partial Autonomy and Actual

Consent“Medical practice which relies on procedures such as routine

signing of „consent forms‟ may meet conditions for avoiding

litigation, but does not show concern for human autonomy as

it actually exists” (175).

Practitioners must make sure that patients, as they actually are, understand what they can

about the basics of their diagnosis and the proposed treatment, and are secure enough to

refuse to ask for changes.

If this condition is met, then even tacit consent can be legitimate consent.

But if this condition is not met, then even explicit consent is not legitimate.

Respecting Autonomy:1. “Respect for autonomy requires that consent be possible to fundamental aspects

of actions and proposals” (176).a) Deception withholds the fundamental aspects

b) Coercion may not withhold the fundamental aspects, but deny anyone choice

2. “Respect for partial autonomy… [requires]… medical practice to avoid treatment which… would

not be refusable by a particular patient in his or her present condition” (176).

a) Manipulation presents information in a misleading or specific way to encourage a specific

decision – intentionally overblowing remote risks, etc.

b) Deals they cannot refuse – Vulnerable populations, using someone‟s diminished

capacities against them.

So how do we respect autonomy?

1. A Physician‟s role is more than getting a signature – it

involves providing information to the patient in a way the

patient can actually understand, and thus enabling the patient

to consent.

a) Both O‟Neill and Savulescu agree on this point – O‟Neill because

we must account for the patient‟s partial autonomy, and

Savulescu because having the right information is essential to

real choice.

2. A Person‟s capacity for decision-making can be altered in a

great many ways, and can vary due to time, place and

condition. Capacity is not an up or down vote.

a) None of us are fully autonomous, both Savulescu and O‟Neill

show us that. But in the medical setting, all sorts of things can

influence us in ways that further reduce our autonomy.