Autonomy and Its Limitations

Abstract

As the leading ethical principle in the Western world, autonomy deserves a detailed discussion. Understood as the right to self-determination, autonomy includes the right to information and protection of privacy. In an ideal situation, a patient with full autonomy participates in all essential medical decisions and consents to every invasive procedure. However, even patients with full capacity have the right to transfer their autonomy to others: to a family member, friend, or to his/her physician. In cases of patients unable to decide for themselves and therefore with limited autonomy, surrogate decision-making is justified. Two aspects of surrogate decision-making deserve special attention. First, loss of autonomy is rarely complete: every person should be offered appropriate information and allowed to participate in decisions within her/his capacity. Second, surrogate decision-making should be based upon the ethical principle of beneficence and not upon autonomy. In other words: while a person with full autonomy may refuse a life-saving treatment, a physician is not ethically obliged to respect a directive by a surrogate decision-maker if this directive is clearly against the patient’s interests. Finally, some persons make advance directives, to be followed in case of their future incapacity to participate in decisions regarding their treatment. While such written or oral directives are helpful, their validity may be re-considered in situations that the person could not foresee at the time of making the advance directive.