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Practical Autonomy and BioethicsReview - Practical Autonomy and Bioethics
by James Stacey Taylor
Routledge, 2009
Review by Robyn Bluhm, Ph.D.
Mar 16th 2010 (Volume 14, Issue 11)

The heart of the book is Taylor's theory of practical autonomy, which he outlines in the first chapter.  The remainder of the book is spent putting his theory into the context of contemporary discussion of autonomy in moral and political philosophy and then considering the implications of his view for key discussion of autonomy in bioethics.

Taylor begins by noting that personal autonomy, that is, the ability to guide one's decisions and actions based on one's own values and desires, plays a central role in contemporary bioethics. Yet, he claims "there has been no concerted effort made by either bioethicists or autonomy theorists to develop and defend an account of personal autonomy that is both theoretically defensible and captures the contours of the concept as it is discussed in contemporary bioethics and contemporary moral philosophy in general" (p. xiv).  Moreover, the term "autonomy" appears to be used in many different ways in both literatures.  

Taylor's attempt to address these problems is to develop a theory of practical autonomy that involves three conditions which must be met in order for an agent to be autonomous with respect to a decision.  The first is the Threshold Condition, which requires that the agent not make a decision that has been affected by another agent who has provided her with information that was meant to lead her to that particular decision.  If the decision has been so affected, then in order to the decision to be made autonomously, the agent must be aware of the way in which it has been affected, or (if she is not aware) must make a decision other than the one that the second agent had intended for her to make. 

Taylor notes that the Threshold Condition is a necessary, but not a sufficient condition, for the agent to be autonomous with respect to her decisions, so he adds a second condition. The Degree Condition states that "the maximum degree to which a person will be autonomous with respect to a decision that she makes will be determined by the degree to which it is the result of a decision-making procedure that she is satisfied with as being her decision-making procedure for making the type of decision that is in question" (p. 8).  Thus, on Taylor's account, decisions may be made more, or less, autonomously.  A third condition acknowledges that agents' decision-making procedures are open to change; the "Tracing Condition" applies in cases in which a person has decided to use a different procedure than usual and requires that in these cases, the degree of autonomy a person has with respect to a decision depends on "the degree to which she was autonomous with respect to the decision-making procedure that she used to make the choice to use an alternative decision-making procedure' (p. 9).

Having set out his theory of autonomy, Taylor argues that it captures the way in which the concept is used by other autonomy theorists (Chapter 2).  He also argues (Chapters 3 and 4) that Harry Frankfurt's influential theory of autonomy, which is in some important respects different from Taylor's own, is actually concerned primarily with identification, rather than with autonomy.  Whereas on Taylor's account, autonomy is an externalist concept, because the extent to which an agent is autonomous depends on other factors than his own beliefs, desires (etc.), identification is a purely internalist notion, having to do with the relationship among the agent's mental states.  Taylor points out that one can identify with a decision that is not autonomous, if that decision does not meet Taylor's threshold condition (i.e. is the result of manipulation by another agent).  In Chapter 5, Taylor again emphasizes the relationship between manipulation and autonomy, arguing that his theory is a "minimally" substantive theory of autonomy because the Threshold Condition places constraints on the kinds of beliefs that can influence an autonomous decision.

In Chapters 6 and 7, Taylor discusses the relationship between the scope of the choices available to an agent and her ability to act autonomously.  He argues that, contra the view that having more choices is better for autonomous decision-making, it may sometimes be the case that having certain choices available can diminish an agent's ability to at autonomously, though he notes that his analysis differs from other arguments for a similar conclusion.  He also argues that some constraints are necessary for the exercise of autonomy.

Chapters 8 and 9 consider the implications of Taylor's theory of autonomy for key debates in bioethics, specifically the relationship between autonomy and privacy/confidentiality (Chapter 8) and autonomy and informed consent (Chapter 9).  Taylor argues convincingly that respect for privacy and respect for autonomy  are distinct issues, but also shows that, because of the potential effects of loss of confidentiality on patients' relationships with their healthcare providers, and thus potentially on their ability to exercise their autonomy effectively, confidentiality is a key issue in bioethics.  Similarly, despite the tendency in bioethics to equate the provision of informed consent with the exercise of autonomy, Taylor demonstrates that these two concepts are distinct and that the purpose of informed consent is to help an agent to enhance the instrumental value of her autonomy, not to protect her autonomy itself.  How satisfying a reader finds Taylor's analysis of these issues will depend on the extent to which he is willing to accept Taylor's view that an agent's autonomy can only be compromised by others if his decision is the result of deliberate manipulation or deception by another agent.

The final chapter expands on a theme that has recurred throughout the volume, which is that autonomy is of instrumental, not intrinsic, value to its possessor.  Taylor noted early in the book that the rise of autonomy in bioethics coincided with a move away from Christian morality as a guiding force in bioethics and the recognition that individuals may have very different value systems.  Thus, the purpose of respecting autonomy in healthcare settings is to allow for individuals' freedom to pursue their own goals.

Despite the title, which may seem to suggest that the book is concerned primarily with autonomy in bioethics, the bulk of the discussion centers on Taylor's theory of autonomy, developing the theory in the context of contemporary moral and political theory.  As such, it may be most beneficial to readers who are well-versed in this literature, though Taylor does do an excellent job of explicating the positions against which he develops his theory.  Taylor's dense style of argumentation makes the book most suitable for professional philosophers, rather than for most students or for an interdisciplinary audience.

One notable exception to Taylor's thorough overview of theories of autonomy is the almost total lack of discussion of relational accounts of autonomy developed by feminist scholars and which are particularly influential in bioethics.  It would have been interesting to see how Taylor sees the relationship between his theory of autonomy and feminist accounts.  The former emphasizes the negative effects of manipulation on an agent's autonomy, whereas the latter emphasize that the negative effects of other individuals on an agent's decisions need not be overtly coercive.

In summary, Taylor's book is based on an impressive knowledge of contemporary theories of autonomy and it clearly and thoroughly situates his own theory of autonomy in this context. His main message with regard to bioethics is that autonomy has only instrumental, rather than intrinsic, value.  Taylor suggests that recognizing this fact will, at least prima facie, "justify greater limitations on third-party interference in persons' medical choices" (p. 156).  Whether this conclusion is justified, however, will depend on other moral issues in addition to the question of the value of autonomy.

 

© 2010 Robyn Bluhm

 

Robyn Bluhm, Ph.D., Department of Philosophy and Religious Studies, Old Dominion University


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