When Beauchamp and Childress wrote their first edition of Principles of Biomedical Ethics, Immanuel Kant figured prominently in their discussion of the principle of autonomy. Now he warrants barely a mention in the same, much revised chapter of the sixth edition. Why the substantial de-emphasizing of Kant’s philosophy, when he wrote such important ethical treatises in which the human ability to make free and autonomous choice is so central? Isn’t his philosophy the basis for our biomedical principle of autonomy? The surprising answer is no, it cannot be. One reason is that Kant’s philosophical use of the principle of autonomy is actually quite different than the biomedical principle. The other answer is that Kant’s principle does not provide a philosophical justification for the protection of patient’s rights. I will explain both of these perhaps surprising claims. But I do believe there is still a role for Kantian autonomy in the discipline of bioethics: it remains a valid criterion (or yardstick) for when physicians should accede to patient requests for treatment.
Autonomous choice for Kant is ethical choice. When we choose a course of action because it is consistent with the Categorical Imperative, we are choosing autonomously because we are freely choosing to obey an ethical law rather than being a slave to our passions and desires—we are not being pushed along by the world, we are initiating a new action for reasons that are somewhat “otherworldly” because they are neither empirical nor material, the ethical law is a priori and therefore “above the fray”. But patients choose a course of action in healthcare for many reasons, and most of these reasons are amoral, and some may even violate Kant’s Categorical Imperative, such as refusing treatment for a non-terminal condition. Kant saw any “suicide” as a violation of the second statement of the Categorical Imperative because human life must never be treated as a means to an end, and suicide abandons life for some reason (intractable pain, depression, despair), thereby treating it as a means, not an end in itself. The point of this is that most decisions in a healthcare setting do not qualify as autonomous under Kant’s framework, because they are not ethical decisions in a strict sense. They are done for personal reasons, which need not conform to moral law.
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