Principle of Respect for Autonomy
Principles that support autonomy can be directed at the
everyday relationships and encounters between persons; at
the constitution, laws, and regulations of a nation-state; and
at the policies of institutions such as hospitals, insurance
companies, schools, and corporations. What ought to be
done to respect autonomy will not be the same at all these
levels and will be a function of a broad social ideology.
The minimal content for casino italiani a principle of respect for
autonomy is that persons ought to have independence, that
is, be free from coercion and other similar interferences.
John Stuart Mill made this the main principle in On Liberty
(1947): No one should interfere with the liberty of action of
another except to prevent harm to others. This obligation
not to coerce others is defensible as an obligation binding on
individuals, private organizations, and governments. Mill
defended his principle of liberty, not because he believed
that there is a fundamental right to autonomy nor that
autonomy is valuable in itself, but because the recognition of
liberty is supported by the principle of utility. This principle
is that an action or policy is right to the extent that it
promotes the greater happiness for the greater number.
However, securing negative liberty does not establish autonomy
as fundamental in moral theory. Other philosophers
have gone further than Mill in their defense of autonomy.
The most widely quoted principle of respect for autonomy
is one of Immanuel Kant’s versions of the categorical
imperative: “Treat others and oneself, never merely as a
means, but always at the same time as an end in himself ” (p.
101). This is frequently expressed as treating others as
persons, and its distinctive Kantian claim is that others
should be treated as rational beings who have their own
ends. A further explanation of this principle is that persons
should be seen as having interests in two senses. First,
interests in those things that are a benefit to nearly everyone,
for example, being free of pain, not being killed, being saved
from dying. A physician can treat a patient without that
person’s consent and still protect these interests. Second,
autonomous persons “take an interest” in things, that is,
have preferences, projects, and plans. Acting only with
concern to serve interests in the first sense, as is sometimes
alleged against uses of the principle of utility, is not sufficient
for respecting another’s autonomy; we must also discover
and take into account the individual’s values and objectives
(Benn). For example, a physician may believe that a surgical
procedure is an effective treatment to relieve the pain of a
patient’s ulcer, but the patient may have a greater aversion to
the risks of surgery than the physician does, and would
prefer a restricted diet and medication. To not solicit, or to
ignore, the patient’s preferences in this matter would not
respect his or her autonomy.
everyday relationships and encounters between persons; at
the constitution, laws, and regulations of a nation-state; and
at the policies of institutions such as hospitals, insurance
companies, schools, and corporations. What ought to be
done to respect autonomy will not be the same at all these
levels and will be a function of a broad social ideology.
The minimal content for casino italiani a principle of respect for
autonomy is that persons ought to have independence, that
is, be free from coercion and other similar interferences.
John Stuart Mill made this the main principle in On Liberty
(1947): No one should interfere with the liberty of action of
another except to prevent harm to others. This obligation
not to coerce others is defensible as an obligation binding on
individuals, private organizations, and governments. Mill
defended his principle of liberty, not because he believed
that there is a fundamental right to autonomy nor that
autonomy is valuable in itself, but because the recognition of
liberty is supported by the principle of utility. This principle
is that an action or policy is right to the extent that it
promotes the greater happiness for the greater number.
However, securing negative liberty does not establish autonomy
as fundamental in moral theory. Other philosophers
have gone further than Mill in their defense of autonomy.
The most widely quoted principle of respect for autonomy
is one of Immanuel Kant’s versions of the categorical
imperative: “Treat others and oneself, never merely as a
means, but always at the same time as an end in himself ” (p.
101). This is frequently expressed as treating others as
persons, and its distinctive Kantian claim is that others
should be treated as rational beings who have their own
ends. A further explanation of this principle is that persons
should be seen as having interests in two senses. First,
interests in those things that are a benefit to nearly everyone,
for example, being free of pain, not being killed, being saved
from dying. A physician can treat a patient without that
person’s consent and still protect these interests. Second,
autonomous persons “take an interest” in things, that is,
have preferences, projects, and plans. Acting only with
concern to serve interests in the first sense, as is sometimes
alleged against uses of the principle of utility, is not sufficient
for respecting another’s autonomy; we must also discover
and take into account the individual’s values and objectives
(Benn). For example, a physician may believe that a surgical
procedure is an effective treatment to relieve the pain of a
patient’s ulcer, but the patient may have a greater aversion to
the risks of surgery than the physician does, and would
prefer a restricted diet and medication. To not solicit, or to
ignore, the patient’s preferences in this matter would not
respect his or her autonomy.
Types of Advance Directives
Advance care planning may lead to written documentation
of the patient’s wishes. Although this documentation can
take the form of a physician’s note documenting a discussion,
patients often complete written advance directives.
These are particularly important in states with formal requirements
about the level of evidence surrogates need to
forgo treatments or in situations in which conflicts are likely.
There are two types of advance directives: proxy directives
and instructional directives. Both proxy and instructional
directives are invoked only if the patient has lost
decision-making capacity. Proxy directives, often referred to
as durable powers of attorney for healthcare, allow patients to
specify a person or persons to make decisions. They are
relatively easy for physicians and other healthcare providers
to discuss with patients and are straightforward for patients
to understand. Proxy directives, however, do not indicate
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76 ENCYCLOPEDIA OF BIOETHICS 3rd Edi t ion
the patient’s wishes, preferences, or values, and used alone
they do not provide any information to the decision makers
about what treatments the patient might have wanted under
the circumstances at hand.
Instructional directives attempt to fill this gap. These
directives, often referred to as living wills, identify situations
in which the patient would or would not want specified
treatments. For example, a patient’s directive might state
that “if I am permanently unconscious or terminally ill, I
would not want to undergo cardiopulmonary resuscitation.”
Documents vary in terms of the scenarios described and the
specificity of the different treatments. Some documents use
general terms such as “heroic measures” or “aggressive care,”
whereas others list the specific interventions in detail.
Instructional directives apply only under the circumstances
specified in the document. If a patient has a directive
relating to treatment in the event of permanent unconsciousness,
the directive will not help in decision making if
that patient has suffered a devastating stroke. Although
advance directives often focus on situations in which the
patient would want to forgo treatment, they sometimes state
circumstances under which a patient would want aggressive
treatment. Finally, on some forms, people have the opportunity
to provide more comprehensive information about
their values and goals in relation both to their lives generally
and to medical care specifically.
of the patient’s wishes. Although this documentation can
take the form of a physician’s note documenting a discussion,
patients often complete written advance directives.
These are particularly important in states with formal requirements
about the level of evidence surrogates need to
forgo treatments or in situations in which conflicts are likely.
There are two types of advance directives: proxy directives
and instructional directives. Both proxy and instructional
directives are invoked only if the patient has lost
decision-making capacity. Proxy directives, often referred to
as durable powers of attorney for healthcare, allow patients to
specify a person or persons to make decisions. They are
relatively easy for physicians and other healthcare providers
to discuss with patients and are straightforward for patients
to understand. Proxy directives, however, do not indicate
ADVANCE DIRECTIVES AND ADVANCE CARE PLANNING
•
76 ENCYCLOPEDIA OF BIOETHICS 3rd Edi t ion
the patient’s wishes, preferences, or values, and used alone
they do not provide any information to the decision makers
about what treatments the patient might have wanted under
the circumstances at hand.
Instructional directives attempt to fill this gap. These
directives, often referred to as living wills, identify situations
in which the patient would or would not want specified
treatments. For example, a patient’s directive might state
that “if I am permanently unconscious or terminally ill, I
would not want to undergo cardiopulmonary resuscitation.”
Documents vary in terms of the scenarios described and the
specificity of the different treatments. Some documents use
general terms such as “heroic measures” or “aggressive care,”
whereas others list the specific interventions in detail.
Instructional directives apply only under the circumstances
specified in the document. If a patient has a directive
relating to treatment in the event of permanent unconsciousness,
the directive will not help in decision making if
that patient has suffered a devastating stroke. Although
advance directives often focus on situations in which the
patient would want to forgo treatment, they sometimes state
circumstances under which a patient would want aggressive
treatment. Finally, on some forms, people have the opportunity
to provide more comprehensive information about
their values and goals in relation both to their lives generally
and to medical care specifically.
