The monolithic concept of autonomy may be fissuring, judging from recent articles in the bioethics journals. In debates over key issues at the beginning and end of life, autonomy has been an important criterion, often the only one, for settling problems. But as academics bat the ball back and forth, it seems that it is beginning to fray.
For example, writing in the Journal of Medicine and Philosophy, three Swedish academics contend that autonomy actually has three elements: competence, the ability to carry out plans, and authenticity. Competence, or decision-making ability, implies a capacity for making personal plans. But one must also possess efficiency, or the ability to put them into effect without external or internal constraints. Finally, truly autonomous decisions must be consistent with one's own higher-order desires.
The question posed in this article is whether paternalism can be justified in order to enhance a patient's "authenticity". For instance, a person who wants to commit suicide immediately after a crippling accident could be restrained in order (paradoxically) to enhance his autonomy because later on he would want to live. A drug addict could be forced to take treatment to recover his true self.
The authors conclude that paternalism, except in a "weak" form is normally not justifiable. However, in an article in the Journal of Medical Ethics, Felicitas Kraemer, of Eindhoven University of Technology in the Netherlands, asks whether the concept of "authenticity" may be more important than autonomy. The focus of her interest is deep brain stimulation for Parkinson's disease, which can restore control in a patient's life but can also have bad psychosocial side effects.
She cites the example of a Dutch man whom DBS rescued from deep depression and physical and mental suffering. However, the DBS also made him so manic that he had been committed to a psychiatric hospital. There doctors gave him a choice: he could be "normal" and depressed, with the DBS switched off, but free. Or he could keep it switched on, making him manic, independent and happy - but institutionalised. He chose the latter.
"To be both autonomous and authentic was not possible for him," comments Kraemer. "In the authentic state, he is no longer able to make any mentally competent, autonomous decisions in the future, and vice versa, when being mentally competent, he does not feel authentic. In this light, one could redescribe his dilemma as a dilemma between autonomy and authenticity."
There seems to be a growing realisation among bioethicists that autonomy is not as simple as it seems. Perhaps it depends on what element is emphasised. This is not just an academic question, as issues like voluntary and involuntary euthanasia depend on it.