Autonomy and long-term care are a remarkably paradoxical conjunction. Individuals need long-term care because they suffer illnesses and incapacities that compromise their ability to function independently or to choose rationally. Yet the standard concept of autonomy in bioethics stresses the ideals of independence and rational free choice, ideals that appear ephemeral in the face of the wide range of impairments that cause individuals to need long-term care. No doubt such individuals are vulnerable and so might benefit from the protection afforded by various autonomy-derived rights such as noninterference. The paradox is that the underlying concept of autonomy involves a view of persons as robust and independent, whereas the reality of long-term care shows individuals who need support and companionship, needs that seem inimical to this ideal. The paradox thus involves the contrast between capacities central to standard views of autonomy and the actual capacities of individuals who need long-term care: independence versus dependence and capacities associated with agency versus functional frailties. The paradox arises when the fragility and vulnerability of individuals needing long-term care are approached from the perspective of the standard view of autonomy that implicitly involves a robust concept of individual capacity.

The standard view of autonomy is a product of the deep and variegated liberal tradition of thought that is at the foundation of contemporary democracy and bioethical thought. In this view, autonomy is primarily a phenomenon involving independence of action, speech, and thought.