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May 1, 2013 | Posted By Paul Burcher, MD, PhD

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.

They are also not necessarily autonomous for a second reason.  For Kant, autonomous choice was rational choice conforming to moral law.  Many of our decisions in a healthcare setting are distinctly irrational, and must be allowed as such in order to preserve patient rights.  If a patient chooses non-treatment of a potentially treatable cancer because she is tired of the side effects of chemotherapy, is this rational or not?  The physician may argue it is not because a cure is still possible, but the patient can respond that it is rational because she now values being comfortable over potentially gambling away the quality of her remaining time for the chance of a longer life.  We would now accept something that Kant did not appreciate:  reason, or at least “reasonableness” may be in the eyes of the beholder. 

What bioethical ethics is left with has been characterized by its critics as “black box autonomy.”  That is, any choice by an informed, competent patient is an autonomous choice, and must therefore be respected.  Choices may be immoral (I remember feeling, if not expressing, moral judgment when a patient of mine chose to abort a planned, previously desired pregnancy, because her husband, “decided to buy a boat instead.”), irrational (“I choose not to have my leg with gangrene amputated because I believe that God will save me with a miracle if He so chooses”), or self interested (“Don’t turn off the ventilator from my unconscious, terminally ill mother until I can fly in and say goodbye”).  This is a postmodern version of autonomy that comes perilously close to, or possibly becomes synonymous with, moral relativism.  If the patient chooses it, and she is informed and competent, it is the right thing for her, and we should do it.

I would like to offer a modifier to the above statement.  Physicians are obligated, with few exceptions, to accept any autonomous choice involving refusal or testing or treatment, but this post-modern stance does not, I believe, extend to requests for treatment.  Here is where Kantian autonomy remains operative within bioethics.  Physician obligations or professional integrity should be guided by rational principles, which, although empirical in one sense, are also morally grounded in the first two descriptions of the Categorical Imperative:  the rules of medical conduct are universalizable, and must never treat a patient as a means to an end, only as an end in herself.  

Using two examples from my specialty (Ob/Gyn) I can illustrate the difference I am suggesting between rights of refusal and right to requested treatment.  I have had patients with terribly symptomatic fibroid uteruses that refused treatment because they felt any surgery that removed their uterus would alter their sense of themselves as women.  While I may not fully understand why this intangible notion of the feminine could be so important that they would suffer physical pain and health effects to maintain it, I am obviously willing to let them make this decision without interference from me once they have heard the medical aspect of their condition.   On the other hand, I recently refused a hysterectomy on a woman with significant heart disease and diabetes on the grounds that the risks of the surgery could not be justified given her minimal symptoms and benign biopsies of her uterus.  The risk/benefit ratio was unfavorable, and despite her desire to proceed, I refused.  

This second case can be understood in a Kantian framework.   I can universalize the duty to decline surgery when the risks of surgery outweigh the potential benefits.  This could be further universalized to state that physicians should never proceed with a treatment when the risk of harm is greater than the possible benefit.  This, of course, is the principle of non-maleficence., now justified by the first statement of Kant’s Categorical Imperative.

So while it would appear that a Kantian sense of autonomy has been banished from biomedical ethics, I argue that it still has a role, albeit limited.  When physicians are asked to perform a treatment or procedure, or when they are deciding which choices should be offered, the Kantian model still holds.  Patients may refuse treatment for any reason provided they are informed and competent.  But only reasonable treatments that conform to standards of care and offer greater benefit than risk should ever be offered or accepted by physicians.  Physicians must still be Kantian, even if patients need not be.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.