Abstract
Mrs. Dekker is a 76-year-old widow. She used to own a pub and has worked hard all her life. She always got on well with her regular customers, but if someone made trouble, she had no difficulties in kicking him out. The customers sometimes said, “Watch it Mary, the customer is king!”96 upon which she would answer, “You are forgetting that I am the empress!” Mrs. Dekker has one daughter with whom she has a good relationship. She lives in a home for the elderly that she finds very pleasant. Due to kidney failure, she has been dependent on haemodialysis for over a year.
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This is the Dutch expression for ‘the customer is always right’.
This nurse sounded a bit annoyed when he told me that “she often says she wants to die, or that she has a written request for euthanasia [in Dutch: euthanasieverklaring] but if you try to respond to that in a serious way, she doesn’t really want to do anything about it. If you ask her whether she wants to die, then, it turns out that she doesn’t really want that after all.”
It is interesting to note the similarities between this view and that expressed by Gerald Dworkin in his later work, who describes autonomy as “a second-order capacity of persons to reflect critically upon their first-order preferences, desires, wishes, and so forth and the capacity to accept or attempt to change these” and who states that: “by exercising such capacity, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are” (1988, 20).
As discussed in Chapter 1, Feinberg, Dworkin, Christman and many others have noted that autonomy is not incompatible with social influences, relationships and the like. Nor does a procedural view on autonomy (as promoted by these authors and Meyers alike) rule out certain values or value systems (such as a strong orientation toward relationships) as non-autonomous. However, keeping in mind Little’s characterisation of the care orientation, the différence is in the emphasis, concern and elaboration this relational side of autonomy receives.
Note that this does not exclusively mean non-interference, but also asks for some positive action such as providing information. The intention of the doctrine of informed consent is to facilitate and promote autonomous decision-making by patients and not just to refrain from interfering with patients’ choices.
An ERCP is an Endoscopic Retrograde Cholangio Pancreatography, a procedure by which a tube is inserted through the oesophagus and stomach into the small intestine to the mouth of the bile and pancreatic ducts. This procedure serves to diagnose and remove gallstones.
In the case of Mrs. Verwoerd (mentioned briefly in Chapter 7), the physician rather forcefully tried to convince her to stay in the hospital. At one time, he bluntly said that he believed her decision to go home to be stupid although he immediately added that he would respect it if she stuck to it. At the time, I wondered whether he was not putting too much pressure on Mrs. Verwoerd (I could imagine her feeling rather intimidated by his remark), but when I later asked Mrs. Verwoerd about it she told me she appreciated the clear and direct way in which her physician stated his point of view. It made her feel taken seriously and respected as a partner in the dialogue.
Actually, this is one of the requirements for competence as discussed by Buchanan and Brock 1990.
It is frequently remarked by care ethicists that the primary question of the care ethic is not “what ought I to do?” but “how ought I to live?”
Cf. Benn’s argument that autonomy is an ideal only available to a plural tradition (Benn 1976).
This makes the complexity of the relationship between autonomy and well-being or beneficence even more clear than it has been until now. While autonomy as a right can conflict with well-being, autonomy as a condition can be understood as an aspect of well-being. As mentioned in Chapter 6, autonomy is an item on the list of things that promote individual well-being. Moreover, in a subjectivist theory of well-being like the one developed in Chapter 6, autonomy is also constitutive of well-being, since well-being, by definition, depends on the critically reflected values, goals and self-identity of a person.
More attention to prevention does not subtract from the necessity of rales or guidelines for cases of conflict. I believe the right to self-determination remains indispensable as a final constraint on the good intentions of caregivers (Schermer 2000). Though the care view focuses on many subjects that remain underexposed in an ethic of rights and duties, it does not provide the necessary safeguards in cases of conflict or abuse of power. Attitudes of attentiveness and responsiveness (Tronto 1993) may be appealed to, but they cannot be enforced in the same way a right to self-determination can. This is one reason to believe that the care view and a rights-based view should be seen as complementary.
The care perspective, however, does offer some starting points for appreciating the value of sovereignty. Making one’s own choices, even if they are non-authentic, stupid or harmful can be conducive to self-respect and self-esteem and can thus indirectly enhance autonomy skills. Moreover, the possibility to learn from one’s foolish or mistaken decisions also offers an opportunity to improve the exercising of autonomy skills such as self-reflection, introspection, self-understanding and the like. Just as we cannot do without others to develop and enhance our autonomy, we cannot do without practice, without learning from our mistakes and without the self-respect that comes from doing or choosing at least some things by ourselves.
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© 2002 Springer Science+Business Media Dordrecht
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Schermer, M. (2002). Who Cares for Mrs. Dekker’s Autonomy?. In: The Different Faces of Autonomy. Library of Ethics and Applied Philosophy, vol 13. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9972-6_8
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DOI: https://doi.org/10.1007/978-94-015-9972-6_8
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