Different Visions of Autonomy
The Valley of Tears, Gustave Doré 1883.
Autonomy means individual freedom, the right to choose what is best for oneself. It plays a very large role in secular bioethics. The Catholic vision of the acting human person is also centered on free will with an emphasis on the view that God created us free in order that we might choose what is true and good. There is always, however, the tragic possibility of deciding to embrace evil or injustice and reject God.
The main problem with a libertarian or liberal view of autonomy is that it lacks strong normative limits. Objective truth tells us when we are abusing autonomy and need to be brought back into the path of sound morality. The liberal view of autonomy is sometimes expressed as, “your right to swing your fist ends where my nose begins.” This minimalist view of the proper curbs on autonomy says that we can do anything we like as long as it does not directly impinge on the rights of others. It can lead to many terrible permissive actions like condoning or even assisting suicide.
It is true that without autonomy we are slaves, and our good actions have little merit as they are coerced. A police state is no one’s ideal or utopia. Totalitarian ideologies attempt to crush autonomy and replace it with conformity to imposed ideas and actions. Punishment and the fear of punishment keep people in line. Surveillance and people spying on and denouncing their neighbors and even family members are a cornerstone of the system. This crushing of the right of autonomy is supremely unattractive.
So where should society and individuals draw the line between anarchy and complete social control? It is clear that freely chosen actions that harm others unjustly must be prevented and punished. I believe a similar imperative applies to choices that harm ourselves. Medicine and bioethics have the useful concept of “competence.” Are patients capable of understanding and making a reasonable decision for themselves? If not, their autonomy should not be respected because their judgment is impaired. This is most clear in the cases of severe mental illness. Catholic wisdom takes autonomy or free choice very seriously and addresses what should be done to assist it. The Church places great emphasis on how our consciences must be informed and guided. Our moral conscience needs to be educated from early childhood and throughout our lives (Catechism of the Catholic Church, # 1783–84). Fallen human nature is a Christian doctrine that starkly acknowledges that people tend to choose evil, even though this is irrational and destructive. The sacraments were instituted to give us grace and help lead us in the proper ethical direction. We have the promise of heaven and the reality of hell to motivate us towards choosing a moral rather than an immoral life.
Making and acting on evil choices is sinful and should not be endorsed or supported. It is also true, however, that freedom or autonomy is a basic human right and should be respected within certain limits. If one tries to enforce virtue in every instance, then one can fall into the totalitarian extreme where the cure is worse than the disease. The proper role of ethics and bioethics is to help make judgments as to where to draw the line between permissiveness and repression.A classic example is medical informed consent. This is a fundamental principle of medical ethics. One cannot force a procedure or intervention on an unwilling patient. Instead, it is important to explain to patients their medical situation and their different options, including the potential risks and benefits of different choices. Medical professionals can and should give their professional opinion as to what course of action they think the patient should follow. But, if the patient refuses or chooses another path, it is not the doctor’s right to overrule the patient’s autonomy. If the patient is choosing something the physician thinks is gravely mistaken, he or she is under no obligation to facilitate that decision. The medical professional has the conscience and autonomy right to withdraw from the care of that patient.
Catholic bioethics would also add that there is a responsibility to attempt to convince patients to do what is objectively good and avoid evil choices. That goes from the highest level of convincing legislators not to permit abortion, assisted suicide, etc., to the lowest level of individual patients. It is difficult to see so many people making self-destructive choices in a society like ours where Judeo-Christian morality and ethics are not the predominant influence on law or medical practice. Our popes since the latter half of the twentieth century have strongly advocated that the Church and Catholics propose the beauty and reasonableness of the truth rather than try to impose it on others who do not see it or reject it. There is definitely a balance to be respected. Forcing others to do everything right is ethically corrosive and self-defeating as it introduces evils in the fight against sin. At the same time, complete permissiveness simply abandons people to fall into temptation and allows the weak and the vulnerable to be abused. Ethical limits must go beyond just preventing injustice against others. We do need protection against making bad choices for ourselves while not destroying personal autonomy. This is why conscience rights are so fundamental. They enable medical professionals and others to refuse to be forced to participate in unethical actions. If a patient is repeatedly told that a choice is inadvisable and no medical person will collaborate with it, this is a minimally coercive way to convince him or her not to do it. We have a duty to educate, to prevent harms, and avoid evil, but God’s immense respect for free will must also be ours.
