Skip to main content Accessibility help
  • Print publication year: 2010
  • Online publication date: February 2011

1 - Autonomy: variations on a principle


As originally used, the term ‘autonomy’, so central to bioethical debate, had nothing to do with health care or indeed with individuals. Rather, the term described the right of Greek city-states to self-government. With the Enlightenment, the principle of autonomy came to be associated with individuals as well as states and respect for autonomy now provides the philosophical underpinning for much of bioethics and law. While this book is concerned with autonomy in the relatively limited sphere of decisions about treatment, the status to be accorded to individual autonomy is central to many bioethical debates, ranging from access to euthanasia and reproductive technology to the sale of organs or body parts.

Although the importance of autonomy to healthcare ethics and law is clear, what the principle actually means is less so. As Gerald Dworkin notes, ‘[a]bout the only features held constant from one author to another are that autonomy is a feature of persons and that it is a desirable quality to have’. In fact, as this chapter shows, the concept of autonomy is more dynamic and complex than is sometimes appreciated in legal discussions of its role in healthcare decision-making. This chapter establishes the theoretical foundations for the legal discussion which follows in later chapters by exploring autonomy as a philosophical construct within ethical debate. This is important not least because, as Alasdair Maclean notes, the law tends to follow the dominant ethical arguments although with an extensive time lag.

Callahan, D., ‘Can the Moral Commons Survive Autonomy?’ (1996) 26 Hastings Center Report 41
Schneider, C., The Practice of Autonomy (New York: Oxford University Press, 1998), p. 3
Wolpe, P., ‘The Triumph of Autonomy in American Bioethics: A Sociological View’ in R. de Vries and H. Subedi (eds.) Bioethics and Society: Constructing the Ethical Enterprise (Upper Saddle River, NJ: Prentice Hall, 1998), p. 43
O'Neill, O., Autonomy and Trust in Bioethics (Cambridge University Press, 2002), p. 2
Dworkin, G., The Theory and Practice of Autonomy (New York: Cambridge University Press, 1988), p. 6
Maclean, A., Autonomy, Informed Consent and Medical Law: A Relational Challenge (Cambridge University Press, 2009), p. 215
Raz, J., The Morality of Freedom (Oxford: Clarendon Press, 1986), p. 204
Raz, J., Ethics in the Public Domain: Essays in the Morality of Law and Politics (Oxford: Clarendon Press, 1994)
Mackenzie, C. and Stoljar, N. ‘Autonomy Reconfigured’, in C. Mackenzie and N. Stoljar (eds.) Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self (New York: Oxford University Press, 2000), p. 4
Pelligrino, E. D. and Thomasma, D. C., For the Patient's Good (New York: Oxford University Press, 1988), p. 7
Keyserlingk, E., Sanctity of Life or Quality of Life in the Context of Ethics, Medicine and Law (Ottawa: Law Reform Commission of Canada, 1979), p. 12
Keown, J., ‘Restoring Moral and Intellectual Shape to the Law After Bland’ (1997) 113 Law Quarterly Review 481, 483
Rothman, D., Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991), p. 9
Veatch, R.Autonomy's Temporary Triumph’ (1984) 14 The Hastings Center Report 38, 38
Toulmin, S.How Medicine Saved the Life of Ethics’ (1982) 25 Perspectives in Biology and Medicine 736
Kesey's, KenOne Flew Over the Cuckoo's Nest (New York: Viking Press, 1962)
Plath's, SylviaThe Bell Jar (London: Faber and Faber, 1971)
Jones, J., Bad Blood (New York: Free Press, 1981)
,National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research, Ethical Principles and Guidelines for the Protection of Human Subjects of Research (Washington: Department of Health, Education, and Welfare, 1979)
Beauchamp, T. ‘The Origins and Evolution of the Belmont Report’ in J. Childress, E. Meslin and H. Shapiro (eds.) Belmont Revisited: Ethical Principles for Research With Human Subjects (Washington: Georgetown University Press, 2005), pp. 12–25
Beauchamp, T. and Childress, J., Principles of Biomedical Ethics (1st edn) (New York: Oxford University Press, 1979)
Beauchamp, T. and Childress, J., Principles (6th edn) (New York: Oxford University Press, 2008)
Spriggs, M.Autonomy and Patients' Decisions (Lanham, MD: Lexington Books, 2005), pp. 56–64
Gillon, R., ‘Ethics Needs Principles – Four can Encompass the Rest – and Respect for Autonomy should be “First Among Equals”’ (2003) 29 Journal of Medical Ethics 307
Beauchamp, T. and Childress, J., Principles of Biomedical Ethics (4th edn) (New York: Oxford University Press, 1994), p. 272
Veatch, R., A Theory of Medical Ethics (New York: Basic Books, 1981)
Engelhardt, T., The Foundations of Bioethics (New York: Oxford University Press, 1986)
Callahan, D.Autonomy: A Moral Good, Not a Moral Obsession (1984) 14 The Hastings Centre Report 40
Pelligrino, E. ‘The Four Principles and the Doctor-Patient Relationship: The Need for a Better Linkage’ in R. Gillon (ed.) Principles of Healthcare Ethics (London: John Wiley & Sons, 1995)
Holm, S.Not Just Autonomy – the Principles of American Biomedical Ethics’ (1995) 21 Journal of Medical Ethics 332
Foster, C.Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law (Oxford: Hart Publishing, 2009)
Clouser, K. and Gert, B.A Critique of Principalism’ (1996) 15 Journal of Medical Philosophy 219
Gaylin, W. and Jennings, B.The Perversion of Autonomy: Coercion and Constraints in a Liberal Society (Washington: Georgetown University Press, 2003), pp. 47–57
Miola, J., Medical Ethics and Medical Law: A Symbiotic Relationship (Oxford: Hart Publishing, 2007), pp. 48–53
Kant, I., Critique of Practical Reason (1785) in M. Gregor (ed.) Kant, Practical Philosophy (Cambridge University Press, 1996)
Gillon, R., Philosophical Medical Ethics (Chichester: John Wiley, 1985), p. 64
Charlesworth, M., Bioethics in a Liberal Society (Cambridge University Press, 1993), pp. 12–13
Kant, I., Groundwork of the Metaphysics of Morals (1785), p. 402, (from M. Gregor (ed.) Kant: Groundwork of the Metaphysics of Morals (Cambridge Texts in the History of Philosophy) (Cambridge University Press, 1997)
O'Neill, O., Constructions of Reason: Explorations of Kant's Practical Philosophy (Cambridge University Press, 1989)
Sullivan, R., An Introduction to Kant's Ethics (Cambridge University Press, 1994)
Secker, B.The Appearance of Kant's Deontology in Contemporary Kantianism: Concepts of Patient Autonomy in Bioethics’ (1999) 24 Journal of Medicine and Philosophy 43
Dan-Cohen, M., Harmful Thoughts: Essays on Law, Self, and Morality (Princeton University Press, 2002), p. 135
Dworkin, R., Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom (New York: Alfred A. Knopf, 1993), p. 224
Feinberg, J.The Moral Limits of the Criminal Law, Vol 3: Harm to Self (New York: Oxford University Press, 1986), pp. 44–7
Smith, A. McCall, ‘Beyond Autonomy’ (1997) 14 Journal of Contemporary Health Law and Policy 23, 30
White, B. Cox, Competence to Consent (Washington DC: Georgetown University Press, 1994)¸ p. 22
Atkins, K., ‘Autonomy and the Subjective Character of Experience’ (2000) 17 Journal of Applied Philosophy 71
Mulhall, S. and Swift, A., Liberals and Communitarians (2nd edn) (Oxford: Blackwell Publishing, 1996)
Rawls, J., A Theory of Justice (Cambridge, MA: Harvard University Press, 1971)
Dworkin, R., A Matter of Principle (Oxford University Press, 1985)
Sandel, M., Liberalism and the Limits of Justice (2nd edn) (Cambridge University Press, 1997), p. 62
MacIntyre, A.After Virtue: A Study in Moral Theory (London: Duckworth, 1981)
Baier, A., Postures of the Mind: Essays on Mind and Morals (Minneapolis: University of Minnesota Press, 1985), p. 85
Jaggar, A., Feminist Politics and Human Nature (Totowa, NJ: Rowman & Littlefield, 1983)
Frankfurt, H.Freedom of the Will and the Concept of a Person’ (1971) 68 Journal of Philosophy 5
Watson, G.Free Agency’ (1975) 72 Journal of Philosophy 202
Christman, J.Constructing the Inner Citadel: Recent Work on the Concept of Autonomy’ (1988) 99 Ethics 109
Christman, J. (ed.) The Inner Citadel: Essays on Individual Autonomy (New York: Oxford University Press, 1989)
Churchland, Paul, Neurophilosophy at Work (New York: Cambridge University Press, 2007)
Dennett, DanielElbow Room: The Varieties of Free Will Worth Wanting (Cambridge, MA: MIT Press, 1984)
Honderich, T., How Free are You? The Determinism Problem (2nd edn) (Oxford University Press, 2002)
Kane, R.The Significance of Free Will (New York: Oxford University Press, 1996)
Koehler, D. and Harvey, N. (eds.) Blackwell Handbook of Judgment and Decision Making (Chichester: Wiley Blackwell, 2004)
Thaler, R. and Sunstein, C.Nudge: Improving Decisions About Health, Wealth, and Happiness (New Haven: Yale University Press, 2008)
Tversky, A. and Kahneman, D.Availability: a Heuristic for Judging Frequency and Probability’ (1973) 5 Cognitive Psychology 207
Redelmeier, al., ‘Understanding Patients’ Decisions: Cognitive and Emotional Perspectives' (1993) 279 Journal of the American Medical Association 72
Redelmeier, D. and Shafir, E., ‘Medical Decision Making in Situations that Offer Multiple Alternatives’ (1995) 273 Journal of the American Medical Association 302
Sunstein, C. and Thaler, R., ‘Libertarian Paternalism Is Not an Oxymoron’ (2003) 70 University of Chicago Law Review 1159
MacKinnon, C.Feminism Unmodified: Discourses on Life and Law (Cambridge, MA: Harvard University Press, 1987)
Wells, C., ‘Patients, Consent and Criminal Law’ (1994) 16 Journal of Social Welfare and Family Law 65, 69
Wells, C., ‘On the Outside Looking In: Perspectives on Enforced Caesareans’ in S. Sheldon and M. Thompson (eds.) Feminist Perspectives on Health Care Law (London: Cavendish Publishing, 1998), p. 255
Sherwin, S. (ed.) The Politics of Women's Health: Exploring Agency and Autonomy (Philadelphia: Temple University Press, 1998), pp. 27–8
Luker, K., Taking Chances: Abortion and the Decision not to Contracept (Berkeley: University of California Press, 1975)
Oshana, M., ‘Personal Autonomy and Society’ (1998) 29 Journal of Social Philosophy 81, 83
Nozick, R.Anarchy, State and Utopia (New York: Basic Books, 1974), p. 33
Mackenzie, C.Abortion and Embodiment’ (1992) 70 Australian Journal of Philosophy 136
Fletcher, al., ‘Legal Embodiment: Analysing the Body of Healthcare Law’ (2008) 16 Medical Law Review 321
Cassell, E., Leon, A. and Kaufman, S.Preliminary Evidence of Impaired Thinking in Sick Patients’ (2001) 134 Annals of Internal Medicine 1120
Wicclair, M., Ethics and the Elderly (New York: Oxford University Press, 1993), p. 55
Brody, B., Life and Death Decision Making (New York: Oxford University Press, 1988)
Cassell, E., ‘Unanswered Questions: Bioethics and Human Relationships’ (2007) 37 (5) Hastings Center Report 20, 23
Spriggs, M.Autonomy in the Face of a Devastating Diagnosis’ (1998) 24 Journal of Medical Ethics 123
Christman, J., ‘Relational Autonomy, Liberal Individualism, and the Social Construction of Selves’ (2004) 117 Philosophical Studies 143, 147
Herring, J., ‘Relational Autonomy and Rape’ in S. Sclater et al. (eds.) Regulating Autonomy: Sex, Reproduction and Family (Oxford: Hart Publishing, 2009), pp. 56–8
Hill, T., Autonomy and Self-Respect (Cambridge University Press, 1991)
Glendon, M. A., Rights Talk: The Impoverishment of Political Discourse (New York: Free Press, 1991), p. 47
Frazer, E. and Lacey, N., The Politics of Community: A Feminist Critique of the Liberal-Communitarian Debate (London: Harvester Wheatsheaf, 1993)
Callahan, D., ‘Individual Good and Common Good: A Communitarian Approach to Bioethics’ (2003) 46 Perspectives in Biology and Medicine 496
Brazier, M., ‘Do No Harm – Do Patients Have Responsibilities Too?’ (2006) 65 Cambridge Law Journal 397, 400
Gilligan, C., In a Different Voice: Psychological Theory and Women's Development (Cambridge, MA: Harvard University Press, 1982)
West, R., ‘Jurisprudence and Gender’ (1988) 55 University of Chicago Law Review 1
Noddings, N., Caring: A Feminine Approach to Ethics and Moral Education (Berkeley: University of California Press, 1984)
Held, V., Feminist Morality: Transforming Culture, Society and Politics (Chicago: University of Chicago Press, 1993)
Scales, A., ‘The Emergence of Feminist Jurisprudence: An Essay’ (1986) 95 Yale Law Journal 1373, 1381
MacKinnon, al, ‘Feminist Discourse, Moral Values and the Law – A Conversation’ (1985) 34 Buffalo Law Review 11, 74
Scott, R.Rights, Duties and the Body: Law and Ethics of the Maternal-Fetal Conflict (Oxford: Hart Publishing, 2002), p. 87
Hardwig, J., ‘Is there a Duty to Die?’ (1997) 27 Hastings Center Report 34, 36
Callahan, D., ‘Our Burden Upon Others: A Response to John Hardwig’ in J. Hardwig with N. Hentoff et al. Is there a Duty to Die? and Other Essays in Medical Ethics (New York: Routledge, 2000), pp. 139–44
Gunderson, M.Being a Burden: Reflections on Refusing Medical Care’ (2004) 34 Hastings Center Report 37
George, K.A Woman's Choice?: The Gendered Risks of Voluntary Euthanasia and Physician-Assisted Suicide’ (2007) 15 Medical Law Review 1
Blackhall, al., ‘Ethnicity and Attitudes Towards Patient Autonomy’ (1995) 274 Journal of American Medical Association 820
Kitamura, al., ‘Image of Psychiatric Patients’ Competency to Give Informed Consent to Treatment in Japan' (1999) 22 International Journal of Law and Psychiatry 45
Kara, M.Applicability of the Principle of Respect for Autonomy: The Perspective of Turkey’ (2007) 33 Journal of Medical Ethics 627
Shore, D. (ed.) The Trust Crisis in Healthcare: Causes, Consequences, and Cures (New York: Oxford University Press, 2007)
Davies, M.Medical Self-Regulation: Crises and Change (Aldershot: Ashgate, 2007), pp. 93–4
Kmietovicz, Z.R.E.S.P.E.C.T – Why Doctors are Still Getting Enough of it’ (2002) 324 British Medical Journal 11
Manson, and O'Neill, , Rethinking Informed Consent in Bioethics (Cambridge University Press, 2007), p. 166
Lawrence, R. E. and Curlin, F. A.Autonomy, Religion, and Clinical Decisions: Findings from a National Physician Survey’ (2009) 35 Journal of Medical Ethics 214
Quinlan, C. and O'Neill, C.Practitioners' Narrative Submissions (Unpublished) (Dublin: Irish Hospice Foundation, 2008)
Green, L., ‘Un-American Liberalism: Raz's “Morality of Freedom”’ (1988) 38 University of Toronto Law Journal 317
Nedelsky, J., ‘Reconceiving Autonomy: Sources, Thoughts and Possibilities’ (1989) 1 Yale Journal of Law and Feminism 7, 10
Nussbaum, M. and Sen, A. (eds.) The Quality of Life (Oxford: Clarendon Press, 1993)
Nussbaum, M., Women and Human Development: The Capabilities Approach (Cambridge University Press, 2000)
Myers, D., Self, Society and Personal Choice (New York: Columbia University Press, 1989), p. 76
Fox, R., ‘The Evolution of American Bioethics: A Sociological Perspective’ in G. Weisz (ed.) Social Science Perspectives on Medical Ethics (Philadelphia: University of Philadelphia Press, 1990), p. 209