Last year, I found myself in the minority during a debate on the topic of personal autonomy*. In dispute was the following case:
A woman (let’s call her Mrs. Jones) has been diagnosed with cancer but refuses to believe what her doctor is telling her. A person with cancer, she believes, would not feel as well as she does; a person with cancer, according to her belief, would rapidly lose weight, whilst she has in fact gained a few pounds. According to her own prior experience with cancer (through word of mouth, film, etc.) it isn’t possible that she has cancer—thus, she refuses to take any medicine or follow any course of treatment.
This question followed:
Q1: Assuming that it is certainly true that Mrs. Jones has cancer, but that she doesn’t believe that she does after being proffered the appropriate evidence, would it be right for the doctor to secretly or forcefully administer treatment?
The class’ overwhelming response was that it would be immoral for the doctor to administer any drugs or medication without Mrs. Jones’ permission. The central principle of autonomy, our moral obligation to respect and protect an individual’s autonomy, had won out over any other (benevolence, nonmaleficence, etc.). Even with an important adjustment to the case, the majority opinion would not sway: it made little difference if we could imagine that the cancer could be treated by something as innocuous or unremarkable as a pill. The issue was not pain, or harm of any sort, but autonomy through and through.
It seemed to me that there was a world of difference between the autonomous choice of one holding a skewed relationship with reality, and the autonomous choice of one acting upon reflection of the facts. Of course, any such consideration was answered swiftly: but surely a part of one’s being autonomous is the ability to choose what one believes.
Now, I think that there is a profound philosophical problem at the root of such an untethered conceptualisation of autonomy. It seems peculiar to think that we could choose what we believe, but even if we could, it seems that our range of choice is limited to a certain educational conditioning. A way of teasing this issue out is to change the situation slightly: let us consider that the only reason that Mrs. Jones is denying the doctor’s assertion is due to her distrust of ‘people of colour’, and that the doctor is a black man. A new question could be (and was) asked:
Q2. Assuming that it is certainly true that Mrs. Jones has cancer, but that she doesn’t believe that she does due to the fact that she does not trust the opinion of any non-white person, would it be right for the doctor to secretly or forcefully administer treatment?
Let us assume that there is no other doctor available, no white authority to ask—either Mrs. Jones is treated by the black doctor, or she swiftly and painfully dies. Still, the majority of my class (though a tad fewer) argued that it would be immoral for the doctor to act against Mrs. Jones’ will. Even when I suggested that we certainly knew that Mrs. Jones would accept the treatment if she herself believed that she had cancer, the class still stood opposed to action—the relationship between belief and truth were not nearly as important as the the agent’s ‘choice’.
I’d like to suggest that a more robust conceptualisation of autonomy would take more into consideration than the childish assertion that action x is autonomous because subject y did it because she “wanted to”. I think we need to pay much more attention to how we conceive of agents and their relationship to the world, specifically when it comes to an agent’s epistemic position. An agent chooses based on certain epistemic considerations: we have beliefs or knowledge about the goals of our actions, what we are capable of doing, as well as the present state of affairs, or the point of action itself.
When it comes to these epistemic relationships, it seems difficult to disavow the important role other agents play.
Consider a colour-blind individual, let’s name him Calvin: I’d argue that it is not plausible that Calvin could come to properly understand his own optical deficiencies without the input of a non-colour-blind individual, or what I would like to refer to as an external perspective on his epistemic relationships (a mediating third element). In this situation, the latter individual would have what we could call an epistemic authority. Imagine the (fantastic) situation in which Calvin (who has trouble distinguishing between red and green) has come into contact with a deadly virus, and is sent by a doctor to get the “green” pills from a medical office, only to find that they are located next to a jar of “red” pills. Calvin, using what beliefs he has about the colours “red” and “green”, tragically grabs the wrong pills. Would we consider it a breach of a respect for autonomy if a second individual, let’s call her Claire, who was not colour blind, were to override Calvin’s choice, and make him take the other pills, even against his vehement objections? Remember, it isn’t that Claire is stopping Calvin from reaching a certain end or goal that he desires (the opposite in fact) but rather that she is exercising a certain authority over Calvin’s epistemic position, something that only a perspective from the outside can achieve.
If an autonomous being is taking a course of action towards a certain goal, but unbeknownst to itself, is mistaken in the course of an action’s relationship to the end, surely we can accept a certain sense of paternalism and epistemic authority whilst still leaving sufficient room for autonomy. It isn’t enough to think about an agent as simply ‘acting’ in a vacuum, or to analyse autonomy without making reference to an epistemic context. Ultimately—and I know a lot of readers will resist this on political grounds—I’m inclined to suggest that a full conception of a respect for autonomy would necessitate the need for certain paternalistic acts, based on the epistemic authority of those who know better than we.
* This discussion and debate took place in Prof. DiSilvestro’s Bioethics course in the summer of 2012. My thoughts on the matter are indebted to Dr. D.’s class.
Department of Philosophy
Sacramento State University