By Xavier Symons and Susan Pennings.
Respect for patient autonomy is perhaps the pre-eminent principle in contemporary bioethics. What else, after all, is more important than respecting the considered preferences of patients and research participants in medicine?
Tom Beauchamp once wrote that “[the] moral value of respect for autonomy precedes and is not the product of a philosophical theory, and no theory is acceptable if it conflicts with this value” (2005, 327). Many contemporary medical ethicists would accept this maxim. At the very least, it would be unusual to read an article in the pages of a mainstream bioethics journal that did not make at least some passing reference to the importance of respect for autonomy. What’s more, some ethicists believe that other important values in bioethics are reducible to a more fundamental requirement to respect patients’ autonomy.
However, attempts to articulate a coherent account of autonomy run into significant theoretical challenges. Our recent article discusses one in particular, which is the problem of inappropriately adaptive preferences. An inappropriately adaptive preference is a preference which is based on and may perpetuate social injustice. We argue that there is no clear way to distinguish inappropriately adaptive preferences and normal autonomous preferences. This presents a problem for both the theory and practice of medical ethics.
The problem of adaptive preferences
For a concept that does so much moral heavy lifting, there are important theoretical challenges to articulating a coherent conception of autonomy for medical ethics. Our article discusses one of these, the problem of adaptive preferences. An adaptive preference is a preference which a person unconsciously forms in light of the options that they perceive themselves as having.
Most relevant for our purposes are what Serene Khader calls “inappropriately adaptive preferences” or harmful preferences that are developed in response to unjust social conditions. Rather than changing the world to allow for the satisfaction of one’s preferences, one changes one’s preferences to suit the otherwise undesirable state of the world. For example, in Jane Austen’s novel Pride and Prejudice, Charlotte Lucas develops a preference to marry the loathsome Mr Collins, not out of love or esteem for Mr Collins, but rather out of pragmatism in a society where single women had little chance of financial security. Charlotte’s preferences have ‘adapted’ to suit her unfortunate social and economic predicament.
What might inappropriately adaptive preferences have to do with autonomy and bioethics? Firstly, inappropriately adaptive preferences may play a part in many patients’ medical choices. For example, a female patient may request repeated cosmetic treatments to eliminate any trace of aging, if she has internalised social prejudices that claim that older women are ugly and not to be taken seriously. Other patients may choose to reject treatment that would extend their lives but leave them with a disability, if they have internalised social prejudices against people with disabilities.
Second, it seems that there is no straightforward way – either at the level of theory or at the level of practice – to clearly draw a dividing line between normal preferences (which are thought to be autonomous and have normative weight) and inappropriately adaptive preferences (which are not). Our article offers an extensive discussion of the philosophical literature on autonomy and preference formation, and we conclude that it is difficult to articulate an account of autonomy which fits with people’s moral intuitions, excludes inappropriately adaptive preferences and is straightforward to use in real-life clinical situations. We note that clinicians should be cautious about satisfying preferences that are based on and that may perpetuate social injustice. It’s not at all clear, however, how we can exercise appropriate caution in medicine while giving pre-eminent importance to respecting the autonomy of patients and research participants.
Where to from here
We do not pretend to have a solution for this deep problem inherent in conventional approaches to contemporary medical ethics. But we do have some suggestions. First, rather than conceptualising autonomy as a principle that is first among equals, it may be better to see autonomy as a principle that should never totally override the other principles of biomedical ethics.
Second, it seems imperative that bioethicists delve deeper into the resources of normative theory to give content to the notion of autonomy, and to more clearly understand how autonomy should relate to other important values in medical ethics. Morality is too complicated, and the consequences of getting medical ethics wrong are too grave, for us to rest content with first approximations.
Authors: Xavier Symons, Susan Pennings
XS: Postdoctoral Research Fellow, Plunkett Centre for Ethics, The Australian Catholic University and St Vincent’s Hospital, Sydney, Australia
SP: PhD graduate, School of Philosophy, The Australian National University, Canberra, Australia
Competing interests: None declared
Social media accounts of the authors: @xaviersymons