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Respect for personhood in medical and psychiatric ethics
Ethics, Medicine and Public Health (2016) 2, 490—498
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DOSSIER ‘‘PERSONHOOD: INTIMITY AND OTHERNESS’’ /Thoughts
Respect for personhood in medical and psychiatric ethics Le respect de l’identité individuelle en éthique médicale et psychiatrique E. Matthews (Emeritus Professor of Philosophy, Honorary Research Professor of Medical, Psychiatric Ethics) University of Aberdeen, 62, Stanley Street, Aberdeen, AB10 6UQ, United Kingdom Received 2 July 2016; accepted 14 September 2016 Available online 22 November 2016
KEYWORDS Liberal medical ethics; Autonomy; Respect
Summary This paper considers a number of questions concerning a central principle of modern liberal medical ethics — that of respect for patient autonomy. This principle is generally interpreted as a consequence of the more fundamental ethical requirement of respect for personhood, defined in terms of the ‘autonomy’ of a rational being. In the context of medical ethics, this is taken to imply that patients, as persons, have the right to make decisions about their own medical treatment or non-treatment. This, it is argued, involves a misuse of the essentially Kantian concept of ‘autonomy’. For Kant, to be autonomous is to be capable of making universal moral judgements, based on impersonal reason alone. In liberal medical ethics, however, autonomy means the capacity to make decisions about non-moral matters such as one’s own interests, on the basis of values which one has arrived at by free and independent thought. These are clearly different conceptions, so that a definition of personhood in terms of autonomy in the Kantian sense will be different from one in terms of liberal autonomy. This casts doubt on whether respect for patient autonomy in the liberal sense is an implication of respect for personhood. It is not clear why a patient’s decisions about treatment ought to be respected simply because they are based on the patient’s own (non-moral) values. There is a further difficulty. ‘Autonomy’, in the liberal conception, seems to be equivalent to ‘decisionmaking competence’. The elements of this are said to be: 1. The capacity to understand; 2. The capacity to reason; and 3. Possession of one’s own developed structure of values. Decisionmaking competence in this sense is not found in all human beings, or in any human being all the time. For example, small children, adults with learning difficulties, and people with brain damage seem to lack all three elements, or to have them only to a limited extent. People with a serious illness may lack all three temporarily. And people with certain kinds of mental disorder may, just because of their disorder, deviate from their own normal structure of values. It seems to follow that not all human beings are fully persons worthy of respect in the liberal sense of
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Personhood and autonomy
491 personhood. This has morally undesirable implications, which suggests problems in the liberal conceptions both of personhood and of respect. It is argued that a satisfactory conception of personhood can be arrived at only by considering the use of terms such as ‘person’ in everyday, non-technical, contexts. It is argued that ‘person’, in such contexts, is almost synonymous with ‘human being’, though with particular reference to the non-biological characteristics of human beings — those in virtue of which we recognize each other as fellow-humans (as ‘one of us’). A human being does not necessarily possess decision-making competence as defined above: so respect for persons cannot depend on such competence, or require us always to accept a person’s own presently expressed decisions about what is best for themselves. It does, however, require us to recognize others as separate selves, with interests of their own, which may differ from ours. A doctor is therefore morally required to give the patient’s interests priority over his or her own, or those of the health care system. If doctors consider the patient’s expressed decision about treatment to be not in the patient’s own interests, they are morally required to engage in dialogue with the patient, in an effort to arrive at a decision which will be acceptable both to the doctor and to the patient. If the patient is unable to engage in such dialogue, because of impaired decision-making competence, then other methods of establishing the patient’s interests must be tried: examples would be proxy decision-making, by someone who is close enough to the patient to be aware of, and concerned for, the patient’s interests; or appeal to the patient’s own advance directives, where available. The most difficult case is that of patients with certain kinds of mental disorder, where the patient’s own sense of his or her interests has become distorted by the very disorder which needs treatment. Only by following an appropriate course of treatment, which the patient may currently reject, is it possible to restore the patient to a condition in which he or she can genuinely engage in dialogue. This, it is argued, makes it morally justifiable in such cases simply to override the patient’s expressed wishes. © 2016 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Éthique médicale libérale ; Autonomie ; Respect
Résumé Cet article s’interroge sur un principe central de l’éthique médicale moderne libérale : celle du respect de l’autonomie du patient. Ce principe est généralement perc ¸u comme découlant d’une exigence éthique fondamentale du respect de l’identité individuelle, laquelle reconnaît l’autonomie de l’être rationnel. Dans le domaine de l’éthique médicale, cette exigence suppose que les patients, en tant que personnes, sont en droit de prendre des décisions concernant leurs choix d’être traités ou non. Certains soulignent que cette prémisse relève d’une utilisation incorrecte du concept kantien d’« autonomie ». Selon Kant, être autonome signifie avoir un jugement moral universel, fondé uniquement sur la raison impersonnelle. Or, au terme de l’éthique médicale libérale, l’autonomie s’exprime par la prise de décision face à des dilemmes d’ordre personnel émanant de valeurs reflétant une pensée libre et indépendante. Ainsi, les approches kantienne et de l’éthique médicale libérale illustrent des conceptions bien différentes de l’autonomie. La définition même de l’identité individuelle en termes d’autonomie au sens kantien est différente de celle de l’éthique médicale libérale. Cela émet un doute à savoir si le respect de l’autonomie du patient au sens libéral implique un respect de son identité individuelle. Par ailleurs, le fait que la décision d’un patient quant à son traitement soit respectée pour seule et unique raison qu’elle soit fondée sur ses propres valeurs et non sur la moralité reste nébuleux. De plus, la notion libérale d’« autonomie » semble correspondre à une capacité à prendre des décisions, qui comprend : 1. La capacité de comprendre ; 2. La capacité de raisonner ; 3. La possession d’une structure de valeurs personnelles développée. À cet égard, cette compétence n’est ni donnée à tous les êtres humains, ni donnée à tous moments. Notamment, les jeunes enfants, les adultes ayant des difficultés d’apprentissage et les gens ayant des lésions cérébrales ne possèdent pas ces qualités ou du moins les possèdent de fac ¸on limitée. Certains atteints d’une maladie grave peuvent voir leurs capacités affectées momentanément. D’autres, possédant un trouble mental, peuvent voir leur structure habituelle de valeurs déformée en raison de ce trouble. Par conséquent, il s’ensuit que ce n’est pas tous les êtres humains qui sont des personnes dont les choix devraient être respectés au terme de la conception libérale de l’identité individuelle. Cette idée a des répercussions morales indésirables, soulevant des problématiques entourant les notions libérales de l’identité individuelle et du respect de celle-ci. Afin qu’elle soit satisfaisante, certains
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E. Matthews soutiennent que la conceptualisation de l’identité individuelle peut être déterminée uniquement en considérant l’utilisation usuelle de termes comme « personne ». Dans ce contexte, le mot « personne » est presque synonyme d’« être humain », quoiqu’il fasse particulièrement allusion aux caractéristiques non-biologiques de ce dernier, en vertu desquelles les humains se reconnaissent entre eux (l’un des « nôtres »). Un être humain ne possède pas nécessairement la capacité de prendre des décisions telles que définies ci-haut. De ce fait, le respect de la personne ne peut ni relever de cette capacité, ni exiger que nous acceptions la décision d’une personne exprimée à un moment donné comme celle qui serait la meilleure pour elle. Cependant, le respect de la personne nous force à reconnaître les autres comme étant des êtres distincts, ayant des intérêts qui leurs sont propres et qui diffèrent des nôtres. Un médecin est alors moralement tenu de mettre de l’avant l’intérêt du patient avant son intérêt ou celui du système de santé. Toutefois, si le médecin juge que la décision qu’un patient exprime quant à son traitement n’est pas dans le meilleur intérêt de celui-ci, il est moralement obligé de s’entretenir avec lui afin d’arriver à une décision avec laquelle les deux partis seront d’accord. Si le patient n’est pas en mesure d’entretenir une telle conversation dû à son incapacité de prendre des décisions, d’autres moyens doivent être employés. Recourir à une tierce personne, qui est proche du patient, qui le connaît assez bien pour savoir et se soucier de ses intérêts et qui aurait procuration pour prendre une décision à sa place ou faire appel de ses choix advenant la présence de directives anticipées, est l’une de ces alternatives. Le cas le plus difficile est celui où les patients sont affligés d’un trouble mental particulier qui déforme leurs intérêts. Ce n’est qu’à l’aide de soins appropriés que les patients, en choix de les accepter ou de les rejeter, peuvent entretenir une conversation sincère. Selon certains, cette réalité rendrait le fait de contrecarrer la volonté du patient moralement acceptable. © 2016 Elsevier Masson SAS. Tous droits r´ eserv´ es.
Autonomy, personhood and liberal medical ethics The principle of respect for patient autonomy is central to modern medical ethics — indeed, it is almost definitive of what counts as ‘modern’. Being modern, in this context, means, above all, conceiving of the doctor—patient relation differently from the way it was seen in more traditional medicine. (In this paper, incidentally, I shall, for brevity’s sake, use the word ‘doctor’ to refer to anyone professionally involved in medical treatment). In more traditional Western medicine, doctors’ relation to their patients was seen as paternalist, that is, as doing what they (the doctors) saw as best for the patient, whether or not patients agreed with them. Patients, for their part, were supposed simply to accept the doctors’ decisions (to ‘obey doctor’s orders’, as it was sometimes, significantly, expressed). But in modern society, that kind of relation is thought to be inappropriate. Modern medical ethics is liberal, in the sense of being based on the central liberal principle of equality of respect for all persons. In the context of doctor-patient relations, that means that doctors must respect their patients as equals, and vice versa. But liberalism can also be seen as the doctrine that respect for persons is above all expressed in accepting their right to determine the course of their own lives. For liberals, that means that patients must make decisions about their own treatment, in the light of their own conceptions of what makes for well-being, even if they differ from those of the doctor, or of society in general. The principle of respect for patient autonomy expresses this. This account, however, raises a number of important, and related, questions. Most central is the question, why we should accept the autonomy principle at all. It undoubtedly has an intuitive appeal, but that must be insufficient in
such an important context as medical ethics. It surely needs a firmer foundation, in some kind of philosophical argument, which would show why this right to decide is so fundamental, and also why, nevertheless, some exceptions to the principle are generally taken to apply, even in liberal thought. The justification of these exceptions is the second question, which needs to be answered. The most notable of them, which will form the principal subject of this paper, is that of treatmentdecisions in certain kinds of mental illness. My aim will be to show that thinking about this exception, above all, requires us to come up with a different, and more realistically-based, account of the ethics of medical decision-making. In order to achieve this aim, I shall first, in the rest of this section, set out what seems to me to be the most common, if usually implicit, philosophical argument for the autonomy principle. In subsequent sections, I shall consider the alleged exceptions mentioned just now, the reasons why they are believed to be exceptions, and the differences between the case of mental illness and other cases. I hope to show that the problems arise largely from some unexamined philosophical assumptions about the nature of personhood, and so of what is meant by the duty to ‘respect persons’. Questioning these assumptions should make it possible to develop a better, and more genuinely liberal, alternative to contemporary orthodoxy in medical ethics, which should be particularly relevant to psychiatry. We should begin with Kant, because I believe that the argument, which underlies the principle of autonomy is essentially supposed to be Kantian. The very use of the Kantian term ‘autonomy’ in expressing the principle indicates that its philosophical foundation is believed to be found in Kantian ethics. In an earlier article [1], however, I argued that we need to take into account some key differences between Kant’s position in general ethics and liberalism in
Personhood and autonomy regard to medical ethics. Although all readers will be familiar with Kant’s moral philosophy, it will be helpful at this stage, I think, to set out what I take to be the relevant elements of Kant’s thought, simply in order to clarify the connection with liberal medical ethics. The most obvious common element is the belief that any ethics worthy of the name must take the distinction between ‘persons’ and ‘objects’ as central, and be founded on the principle that persons ought to be treated, in Kant’s words, as ‘ends in themselves’, as having an intrinsic value. (Objects, by contrast, have value only instrumentally, as ‘means to an end’). Thus, ‘respect for persons’ amounts to ‘respect for personhood’. It is essential therefore to clarify what is meant by ‘personhood’. For Kant, what distinguishes persons from objects is ‘autonomy’, in the sense of the capacity to reason, above all, to formulate universal moral principles. These principles are ‘universal’, in that they are based, not on the personal feelings, desires, interests, etc. of the individual who formulates them, but on criteria acceptable to all beings capable of reasoning, no matter what their individual feelings, desires and interests might be. Thus, a being of a species quite different from our own, with quite different emotions, desires and needs, but with the capacity to reason, could accept such principles [2]. Kant thus introduced the concept of autonomy in the context of an attempt to define what it is to be a moral agent. Autonomy, for him, is a property of the will, ‘by which it is a law to itself (independently of any property of the objects of volition)’[3]. Autonomy is the capacity to make strictly objective, or rational, judgements about what is, or is not, a moral duty, or at least morally permissible. We human beings, in virtue of our possession of reason, are capable of making such judgements, and, because we have free-will, of acting in the light of such judgements — acting for reasons, rather than being impelled to act by causes (emotions, inclinations, desires, etc.). It is because persons are, by definition, autonomous in this sense that they have dignity: and our autonomous will is ‘the proper object of respect’ [4]. Human beings have dignity, and deserve respect, in so far as they are persons. To make the point clearer, we should expand the argument in more detail. ‘Autonomy’ is, of course, a metaphor drawn from political thought. An ‘autonomous’ state is one which makes its own laws, independently of any other state. All rational beings, Kant argues, are both citizens and legislators of a metaphorical state, which he calls a ‘kingdom of ends’ — ‘a systematic union of various rational beings under common laws’ [5]. To be a moral agent at all is thus to be obliged to recognize other persons as other moral agents, fellow-citizens in the kingdom of ends, and therefore to be treated with the same respect that we rightly demand for ourselves as persons. Setting out Kant’s position in this detail makes clear how different it is from that of liberal medical ethics. What is common to the two positions is a conception of the capacity to make rational decisions as central to what it means to be a ‘person’; what makes them different are contrasting understandings of ‘rationality’. For Kant, with his primary concern with moral agency, to be ‘rational’ is to be free of any influence from personal, or ‘subjective’, considerations of emotion, desire, self-interest, inclination, or impulse. For the liberal medical ethicist, concerned with achieving
493 the best outcome for oneself as a patient, to be ‘rational’ is rather to make decisions based on clearly thought out conceptions of one’s own of what will achieve one’s own longer-term well-being. These conceptions must, of course, be based on one’s own understanding of what one feels, desires, considers to be in one’s own self-interest, and so on. A good illustration of the difference might be found in certain kinds of life-or-death decisions. A fairly standard case in medical ethics is a decision that might face a cancer patient about whether to agree to a particular kind of medical intervention, such as chemotherapy, which might prolong one’s life for a time, but only at the cost of suffering or distress which one might find unacceptable. The patient exercises autonomy by thinking whether it is more in line with her own conception of her well-being to have a longer life, or to avoid this kind of suffering. If the latter is more important to her, she refuses the treatment, that is, accepts the likelihood of an early death. Kant talks of a case, which is in some ways parallel, but his response to it is illuminatingly different. Suppose, he says, we think of someone who ‘feels sick of life because of a series of troubles that has grown to the point of despair’ [6]. He asks himself if it would be morally acceptable, because of this, to take his own life in order to avoid prolonging this suffering, and sees (according to Kant, at least) that to think that would be to say it was a universalisable moral principle that one should shorten one’s life when its prolongation ‘threatens more troubles than it promises agreeableness’ [7]. Since this ‘principle’ would, in Kant’s view, be selfcontradictory, in that it proposes ‘to destroy life by means of the same feeling whose destination is to impel toward the furtherance of life’, he rejects suicide, thereby exercising his autonomy. For Kant, in short, the question does not concern what would promote one’s own well-being, but what could be an objective moral principle for all rational beings. Rationality, for him, consists in thinking in universal terms, not simply in thinking clearly about one’s own best interests. When one considers these examples, it becomes obvious, I think, that the Kantian argument set out above cannot provide a basis for respecting personhood in the way required in liberal medical ethics, because it is based on a different, though superficially similar, concept of ‘personhood’. ‘Rationality’, and so ‘autonomy’, have different meanings in the two cases. In so far as a patient has autonomy in the modern sense, it is because she has the capacity to become aware of her own deepest values, and to think through the connection between them and particular forms of action or refusal of action. She is capable of reasoning in that sense, but her reasoning aims, not at discovering what is objectively true from an ethical perspective, but only at deciding what is subjectively more important to her. What she arrives at, in short, is a way of thinking about her life which is authentically her own, but even to say that is to accept that it is not ‘objective’ or ‘universal’, a requirement for all rational beings as such. Thus being ‘rational’, in this sense, does not make one a fellow-member of a kingdom of ends, and so does not qualify one as deserving to be treated with respect as an end-in-oneself by other members. There does not seem, therefore, to be any Kantian ethical basis for respect for patient autonomy.
494 Allen E. Buchanan and Dan W. Brock, in their book Deciding for Others, take it for granted that respect for a patient’s self-determination should be understood as respect for ‘a person’s interest in making significant decisions about his or her own life’ [8]. This is not, however, in itself an argument for respecting that interest. It is simply a restatement of the liberal point of view — that individual ‘authenticity’ is always a good thing. In the same vein, Becky Cox White, in her Competence to Consent, argues that autonomy is morally important ‘because autonomous persons develop moral principles to guide and evaluate behavior’ [9], and implies that it must be equally worthy of respect when it is applied to non-moral values. But this implication does not follow. It may be argued, on Kantian lines, that moral agency deserves respect, and that an action is only genuinely moral if it proceeds from principles which one has arrived at by the use of reason; but ‘non-moral values’ are only personal preferences, so that it seems to make no difference whether they are arrived at by personal reflection or by conformity to social norms. Again, the underlying assumption of the value of individual authenticity in itself is more a matter of liberal dogma than of an arguable position.
Are there exceptions to the autonomy principle? For Kant, ‘autonomy’ is a defining characteristic of a person, part of what it means to be a ‘person’. In the liberal view, which we are considering, however, ‘autonomy’ is effectively identified with self-determination, with creation by individuals of a set of (non-moral) values which are authentically one’s own. This is something which, as a matter of empirical fact, human beings cannot achieve unless they possess certain cognitive abilities — those required to make decisions about one’s own welfare, or, as it is often expressed, ‘competence’. Possession of competence is not a defining feature of human beings: it is a matter of empirical fact that some human beings have it, others do not, and that those who have it can have it to varying degrees. The self-same individual, moreover, can be competent at one time, or in one respect, but not at other times or in other respects. Thus, not all human beings can be regarded as ‘autonomous’, in the sense current in liberal medical ethics: if respect for personhood is so closely tied to the possession of autonomy (competence), then how are we to respect those who lack competence, or have it only in a diminished form? To answer this question, we need first to ask what is meant by ‘competence’, and so by its lack. Buchanan and Brock list three main requirements to be satisfied if a person is to make competent decisions, about health care or anything else. First, the person must have the capacity for understanding and communication; second, the capacity for reasoning and deliberation; and, third, ‘the individual must have a set of values or conception of the good’ [10]. Becky Cox White elaborates on the third condition. As was said earlier, she emphasizes the ‘non-moral values’, by which we make decisions about our own behaviour and the sort of treatment we desire from others. Autonomous behaviour is exhibited, she says, in two morally neutral ways:
E. Matthews • we can choose our own ‘value-structure’, that is, a set of morally-neutral principles in terms of which we can construct lives which have value for ourselves; • we can use our value-structure to make particular decisions about how to conduct our lives [11]. All three take time to develop. Newborn babies have not yet developed the relevant intellectual capacities, and so have not yet been able to formulate a value-structure. As a rule, the intellectual capacities will gradually develop as the child grows into an adolescent and then an adult; and a value-structure may emerge over that same period, though experience suggests that it will seldom be coherent, clear or systematic. It will not usually be the product of disciplined reflection on general principles, but more of haphazard intuitions about particular experiences, which the individual human being may have had. At all events, this need for development over time implies that ‘competence’ will be non-existent at birth, and will only gradually develop through infancy, childhood and youth. If lack of competence removes the need to respect competence, and a lower degree of competence implies diminished respect, then babies, children and pre-adults will be one exception to the universal duty to respect autonomy. Intellectual capacities do not only require time to develop, but in human beings they also depend on the presence of functioning brain systems of the appropriate kind: moreover, they can only continue to exist for as long as these brain systems continue to function. Another kind of exception, therefore, will be constituted by those human beings whose brains do not function in the required ways, either as a consequence of hereditary abnormalities (resulting in learning difficulties) or because of postnatal brain damage caused by injury or disease. Again, if we accept the equation of autonomy with competence, and the respect due to patients to respect for their competent decisions, then patients who lack certain kinds of brain function will not, in the liberal account of medical ethics, have a right to this kind of respect. But it is arguable that the liberal account also gets into difficulties in much more everyday cases. Fully grown adults, with normally functioning brains, may well find it difficult to arrive at a decision about treatment which is ‘authentically their own’. This may be partly or wholly because they have never formulated one of White’s ‘value-structures’, or at least not one, which is clear, systematic, and coherent. ‘How much do I want to stay alive, perhaps for only a fairly short time longer, if that can be achieved only by submitting to chemotherapy?’ is an example of a relevant question to which few ‘value-structures’ could provide a clear and useful answer. In addition, decisions of this kind often have to be made when patients are not feeling at their best because of their condition, and experience shows that that is not an easy situation in which to think clearly about the future.
Mental disorders One other kind of generally recognized exception to the principle of respect for autonomy is different in kind from those considered so far. It is the main focus of this paper, and the examples considered above are included largely for
Personhood and autonomy the sake of contrast with it. This is the case of patients with certain kinds of mental disorders. Not all generally recognized mental disorders come under this heading. Patients with agoraphobia, for instance, normally recognize that they have a problem which is causing them distress, but which could perhaps be relieved by treatment: in this way, they are in much the same situation as patients with most somatic illnesses. Some kinds of mental disorder, however, are importantly, and relevantly, different from somatic illnesses. As said above, suffering from any kind of illness can reduce one’s capacity to engage in intellectual activity, such as reasoning. People who are seriously ill because of a somatic condition often find it difficult, therefore, to think clearly about what they want to happen to them. The case with this kind of mental disorder is different: patients may be just as capable of thinking clearly about themselves, but their disorder distorts the rationality of their thinking, in the sense of the conformity of their conceptions of what is good or bad in life to criteria of reasonableness which are generally accepted, and which they themselves would accept if they were not suffering from this disorder. The effect is that they do not recognize that they are ill, and suffering, and so that they need help to alleviate that suffering. Two examples may help to illustrate this point. First, people with certain kinds of psychosis will very often fail to recognize their condition, or even vehemently deny that there is anything wrong with them. If so, they may refuse to consent to treatment, which, as others can see, would help people like them. This refusal could even be said to be quite rational from their own point of view: who, after all, would think it sensible to accept treatment for an illness they were convinced they did not have? Another, and rather different, example might be people suffering from anorexia nervosa who reject their doctors’ suggestion that they should eat, even though it is clear to those doctors (and to any other objective observer) that, unless they take this advice, they will continue drastically losing weight in a way which will be ultimately fatal. From the point of view of persons with anorexia, however, it seems plain that they are in fact overweight, so that it is not rational to engage in what they would see as excessive eating. Buchanan and Brock say in their book that one of the virtues of their analysis is that it applies equally to mental and physical illness. But they then go on to say that there are several important differences in the case of mental illness which require a separate discussion, including the fact that the illness itself ‘often, although by no means always, impairs the person’s ability to make a competent decision about his or her need for treatment’ [12]. This manner of expressing the difference seems to me to underplay its significance, and to reveal an essential problem in their definition of ‘competence’. As said earlier, that definition includes both the possession of certain basic intellectual abilities and the use of those abilities to formulate a ‘value-structure’, which will be, in the phrase I have used, ‘authentically one’s own’. Determining whether someone does, or does not, have the required intellectual abilities is relatively straightforward. If they do not, or do not have them yet, then they are not ‘competent’, and so are clearly incapable of making competent choices of treatment or non-treatment. On the other hand, deciding whether someone who clearly has
495 the intellectual capacities has used them to make a ‘competent’ decision is much more difficult, if there is any doubt about the rationality of the value-structure implied. Consider the following two examples. The first is familiar from the literature of medical ethics: it is the case of a Jehovah’s Witness (an adult) who, on religious grounds, refuses a blood-transfusion, even when medical opinion is clear that this is the only way to save her life. Nevertheless, the received opinion among ethicists is that respect for autonomy implies acceptance of this refusal. The second example is the one mentioned earlier, of a person with anorexia who refuses nutrition, even after being told that it is essential if she is to avoid a painful death. Here there would almost certainly be less of an inclination to accept her refusal. Why should there be such a difference? To most of us, it seems irrational to refuse to save one’s life in either of these situations. The difference seems to be that the Witness is presumed to have formed the beliefs on which her decision is based by her own reflection on her experience, whereas the person with anorexia decides on the basis of feelings of revulsion produced, not by her own reflection, but by the illness from which she is suffering. We can expand on this by considering a fundamental difference between mental and somatic illness which is relevant to the ethics of treatment-decisions. Somatic illness, as the very name implies, affects bodily organs and systems, preventing them from functioning efficiently to make possible species-normal life, or, in the worst cases, preventing them from functioning at all, leading to death. Reflection on its debilitating, disabling and painful effects may also lead to changes in patients’ personalities, their whole view of life and what is good or bad about it from their point of view. But it is not the disease or illness itself which causes these changes: it is the patient’s own reflections on its effects. That is because they retain a ‘self’ with all the values which they have come to accept as ‘authentically their own’ (or, if their values change, it is as a result of their own reflection on their present experiences). By contrast, the kind of mental disorder which we are considering here may well involve changes in bodily organs, most likely the brain. But what makes it a ‘mental’ disorder is that it affects the ‘self’, that is, the way one characteristically thinks and feels about the world and other people, and so the conceptions one has about what would be for one’s own best in the longer-term. It is the self, which is disordered, so that the sufferer cannot detach herself from the disorder in order to decide on treatment or non-treatment. What this implies about the question of respect for those with mental disorders can best be discussed in the final section of the paper, after the concept of personhood has been re-examined in Personhood and respect reconceived section.
Personhood and respect reconceived If respect for persons is a fundamental principle of medical (or any other) ethics, it must be because there is something about the concept of a person, which ethically requires respect. The nature of that ‘something’, moreover, will determine just what we mean by ‘respect’. In this section, I shall try to elaborate, in the light of the earlier discussion in this paper, a concept of personhood which I hope will avoid
496 the essential problems found in the principle of respect for patient autonomy. A preliminary methodological question arises: how are we to arrive at a satisfactory concept of a person? That in turn raises a further question: what do we mean by ‘satisfactory’? One way in which it could be said that the Kantian concept of personhood was unsatisfactory is that it is arrived at by entirely a priori reasoning. It is designed, not to reflect what we commonly mean by a ‘person’, but to make it easier to argue for the need to respect personhood. For Kant, as argued earlier, human beings are distinguished from the rest of nature (that is, are ‘persons’) in as much as they are rational beings, ends in themselves, beings capable of making laws for themselves which do not depend on anything empirical, such as the motives and inclinations which may happen to influence them, but only on our reason. To be rational is also to be capable of determining oneself to act, simply in rational recognition of these laws, without any causal influence from the empirical forces of human nature in general, or of one’s own particular experience. The rational will is not ‘constrained by something else to act in a certain way’ [5], but acts freely, on a ‘law’ which ‘arise[s] from his will’. That is, the rational will is autonomous, completely self-determining. To ‘respect’ a person is thus to allow, indeed to promote, his or her autonomy, or capacity for free self-determination, unconstrained by subjective interests, wishes, or desires. The autonomy principle in liberal medical ethics in effect attempts to apply this Kantian argument to cases in which decisions have to be made, not about the morality of an action, but about medical treatment and its likely consequences for the well-being of a patient (where what counts as ‘well-being’ is determined by the patient’s own conceptions). But there is clearly no analogy between the two cases. Kantian moral principles are supposed to be objective and universal, but individual conceptions of well-being are subjective and particular. The claim that my decisions must be respected just because they are mine is, as already suggested, little more than an assertion of liberal dogma: that each individual subject is an infallible authority on what counts as his or her good. That rests on a concept of personhood, which is every bit as abstract and a priori as Kant’s. A ‘more satisfactory’ concept of personhood would be one, which was more realistic, in the sense that it gave an account of what it is to be a person, which fitted better with what we actually mean by ‘person’ in more everyday contexts. In terms of philosophical methodology, this could be called a ‘Wittgensteinian’ approach, though it also could be described as ‘phenomenological’, in a broad sense of that term. In either case, the justification of this approach is that any more theoretical use of the term ‘person’ (in law or ethics, for example) must be derived from its more everyday use if it is to refer to the same beings: clearly, in any medical ethics which is to have a practical application, ‘respect for persons’ must mean ‘respect for persons as ordinarily understood’. The account of personhood which we give should also clarify just what is meant by ‘respect’ for persons. So what do we mean by a ‘person’ in everyday discourse? The term seems to be synonymous, or almost so, with ‘human being’: only a few philosophers, motivated again by the demands of their own theories, rather than those of everyday use and ordinary ethics, would deny that all human
E. Matthews beings are persons. If I say that ‘person’ is only almost synonymous with ‘human being’, it is for two main reasons. First of all, because to refer to a human being as a ‘person’ is specifically to pick out certain non-biological features of humanity (to be discussed below). Secondly, because we seem to be prepared at least to conceive of certain creatures which are not biologically human as ‘persons’ in view of their possession of these non-biological features. To conceive of the possibility of non-human persons is not necessarily, of course, to affirm that any such beings actually exist. It is relevant to say, however, that when we say that a chimpanzee, or a pet cat, is ‘almost human’, we are regarding the animal as almost a ‘person’, having some of the rights to moral respect that human beings have (the rights corresponding to those non-biological properties which we think they share to some extent with human beings). What are the ‘non-biological features’, which lead us to regard human beings as persons? The biological features are those picked out in taxonomy as defining our species. We are, for instance, mammals, with upright gait, bipeds, with opposable thumbs, and so on. For life-scientists, these are the most significant characteristics. In everyday, pretheoretical, life, however, other features are usually of primary importance. Although we may recognize a creature as a human being because of these biological features, what matters most of all to us in most cases is that he or she is ‘one of us’: a potential friend or enemy, a colleague or competitor, a good companion or a bore, maybe a sexual partner, a customer or client, a fellow-citizen of the same state or an alien, someone who shares interests with us or doesn’t, and so on. Being ‘one of us’ is being in, or being capable of being in, these kinds of relationship to ourselves, and it is in being ‘one of us’, in this sense, that a biologically human being comes to be regarded as a ‘person’. Someone is capable of being so related to us (and we to them) only in so far as they can communicate with us. That implies both that they are separate from us (separate selves) and that they can nevertheless overcome this separation at least to some extent by relating to us in this way. Each person, we might say, is a separate ‘I’, with thoughts, feelings, desires, and experiences of his or her own, but is capable of conveying those thoughts, etc. to other human persons, and even of sharing thoughts and feelings with others as parts of a ‘we’. In most adults, the normal, though not the only, means of conveying thoughts, feelings, etc. is in verbal language, which is shared by both the person communicating and the one communicated to. But there are other means of communication, used by adults some of the time, and by children more of the time (in newborn infants, all of the time). These include facial expressions, gestures, body-language, and non-linguistic sounds. These non-verbal means of communication again presuppose a shared understanding of meaning between the communicating partners. To be a person, in short, is to be an ‘I’, an individual subject, essentially capable of such communicative relations to other individual subjects. Even a newborn human baby is a person in this sense, as are people with inborn defects in brain functioning, people with brain injuries or diseases, and people with mental disorders. Their communicative ability may be limited, but they exhibit it in responding to other human beings in peculiarly ‘human’ ways, including responding to others’ responses to them. Being an ‘I’ is thus
Personhood and autonomy essentially being in communication with other selves — being ‘one of us’. We formulate our thoughts in words, which we necessarily share with others. We develop our thoughts in dialogue with others, either literally, or at least in inner ‘conversation’ with them. Our ‘value-structures’, with whatever degree of clarity and coherence they may have, are one of these ways of developing our thoughts. For each person, their conceptions of personal well-being will be specially their own, in that that they will be the result of their own reflection on their own experience; but that reflection will necessarily have taken place in the context of their relations with others, guided by shared standards. They will not be the product of a subject, standing above the fray, like Kant’s rational person. And they will be continually liable to change, in the light of changes in circumstance and of dialogue with others. What is the bearing of this on the ethics of treatmentdecisions in health care? To respect a patient as a person must be, at the very least, to regard the decision about treatment as one to be made in the best interests of the patient — not in those of the doctor, or the health care system, or the state, or any other person or institution. It is, after all, the patient’s life and well-being, which are at stake here. If, however, we take a realistic view of personhood, as outlined above, then it does not follow from this that the patient has the right to have whatever treatment seems to him or her at a particular time to be the best. As was said earlier, even normally intelligent adults are not always clear, particularly when ill or frail, about what their own interests are, or how particular treatments may affect them. At least, however, normally intelligent adults can be engaged in dialogue, with the doctor and/or with others, in an attempt to discover what is in their own interests. Respect for patients as persons then requires doctors to engage in such dialogue with patients, on a footing of equality, in which doctors can offer the benefits of their scientific expertise and clinical experience for consideration by the patient. The decision would then be, not that of the patient alone, but the outcome of this cooperation between doctor and patient. It may well be that the existential nature of many medical situations will mean that such decisions, arrived at in this way, may change the patient’s ‘value-structure’, rather than simply reflecting one which is already fixed. Not everyone, of course, is a normally intelligent adult, with functioning mental capacities. But, as argued earlier, that does not mean that such others are not persons, deserving of respect. The guiding principle in deciding on treatment must still be that whatever is done is done in their interests. The difference is only that they do not have the capacity to formulate a value-structure, or do not have it to the same extent as normally intelligent adults. They do not even have the capacity, which normally intelligent adults have to engage in dialogue with doctors in order to arrive at a decision about treatment. The answer must be, therefore, as most writers on medical ethics would agree, to refer such decisions to a proxy who can be relied on to care about the patient’s interests as much as the patient would, or, in appropriate cases, to take into account advance directives agreed to by the patient when in full possession of adult capacities. This, as I say, would be generally agreed. The difference is only that I am arguing that such reliance on proxies is not an exception to the rule of respecting
497 patients, but is itself a way of respecting patients as persons.
Respecting those with mental disorders Mental disorder, as I argued in section ‘‘Mental disorders’’, differs in important ways from somatic disease or illness. These differences have led some writers, most notably Thomas Szasz [13], to reject altogether the concept of mental disorder as an ‘illness’, requiring medical treatment. This is not the place to discuss such views, however: what is important from the present point of view is that mental disorders are, in the generally accepted view of modern culture, regarded as sources of human distress, which can, and ought to, be alleviated by medical or quasi-medical treatment. If so, the psychiatrist—patient relationship becomes one variety of doctor—patient relationship, raising similar ethical problems. Similar, but not the same. In the case of somatic illness, there may be a problem about whether the patient has, or has yet, or still has, the intellectual capacity to make decisions about his or her own treatment. This is not the problem in the case of mental disorder. People with mental disorders are as likely to have such intellectual capacity as any other adult human being: the disorder affects, not their intellect, but their view of the world, other people, and themselves. Because of this, it affects the very values, which are relevant to making decisions about their interests. Thus, a person with depression feels suicidal, not because they have reflected on the real hopelessness of their lives and decided to end it all, but because of whatever is causing their disorder. Someone with anorexia nervosa finds the idea of eating disgusting, not because she is aware of the health risks of being overweight and wishes to avoid them by dieting, but because of the disorder. The disorder consists in part of these abnormal value-judgements and the ways of perceiving the world on which they rest. Its successful treatment, therefore, must consist in large part in restoring to the patient a way of perceiving which is not so caused, which is more genuinely the person’s own. Clearly, therefore, a person with the disorder is unlikely to be able to choose appropriate treatment, however intelligent they may be. It will, in all probability, be impossible even to enter into useful dialogue with them, in order to arrive at a genuinely agreed solution. How, then, do we respect their personhood in decisionmaking? It seems that we can only do so by allowing someone else to make the decision on their behalf, as is allowed in most mental health legislation in most jurisdictions of which I am aware. This may involve imposing on patients a form of treatment, which, in their present state, they would refuse. How can this be ‘showing respect for the patient as a person’? It can only be if it is assumed, and rightly assumed, that this treatment is not chosen because the psychiatrists, or the institution, favour it, but because that is what the patient would have chosen if he or she were unaffected by this disorder. Making this assumption is, in most cases, a leap of faith, which can only be seen to be justified subsequently, when and if the patient genuinely recovers. It is reasonable, however, to say that no treatment, which makes it impossible for the patient to be
498 restored to normal decision-making capacity (for example, forms of psychosurgery) can be regarded as showing respect to the patient as a person. If all else fails, such treatments may be acceptable as alleviating the patient’s distress, but they cannot be described as respectful to personhood. It might be objected that what I have described and recommended in this paper is simply what is actually done by sensible doctors. That, however, so far from being an objection, is an endorsement of what I have said. The point of the paper is not to offer a novel account of clinical practice. It is rather to show the desirability of making the theoretical account which we give of the ethics of decision-making correspond more closely to what actually happens and to a more realistic conception of human personhood.
Disclosure of interest The author declares that he has no competing interest.
References [1] Matthews E. Autonomy and the psychiatric patient. J Appl Philos 2000;17(1):59—70. [2] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 34.
E. Matthews [3] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 47. [4] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 46—7. [5] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 41. [6] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 31. [7] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 32. [8] Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision-making. Cambridge/New York: Cambridge University Press; 1989. p. 36—7. [9] White BC. Competence to consent. Washington, DC: Georgetown University Press; 1994. p. 14. [10] Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision-making. Cambridge/New York: Cambridge University Press; 1989. p. 23. [11] White BC. Competence to consent. Washington, DC: Georgetown University Press; 1994. p. 15—6. [12] Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision-making. Cambridge/New York: Cambridge University Press; 1989. p. 311. [13] Szasz TS. The myth of mental illness. London: Secker and Warburg; 1962.
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DOSSIER ‘‘PERSONHOOD: INTIMITY AND OTHERNESS’’ /Thoughts
Respect for personhood in medical and psychiatric ethics Le respect de l’identité individuelle en éthique médicale et psychiatrique E. Matthews (Emeritus Professor of Philosophy, Honorary Research Professor of Medical, Psychiatric Ethics) University of Aberdeen, 62, Stanley Street, Aberdeen, AB10 6UQ, United Kingdom Received 2 July 2016; accepted 14 September 2016 Available online 22 November 2016
KEYWORDS Liberal medical ethics; Autonomy; Respect
Summary This paper considers a number of questions concerning a central principle of modern liberal medical ethics — that of respect for patient autonomy. This principle is generally interpreted as a consequence of the more fundamental ethical requirement of respect for personhood, defined in terms of the ‘autonomy’ of a rational being. In the context of medical ethics, this is taken to imply that patients, as persons, have the right to make decisions about their own medical treatment or non-treatment. This, it is argued, involves a misuse of the essentially Kantian concept of ‘autonomy’. For Kant, to be autonomous is to be capable of making universal moral judgements, based on impersonal reason alone. In liberal medical ethics, however, autonomy means the capacity to make decisions about non-moral matters such as one’s own interests, on the basis of values which one has arrived at by free and independent thought. These are clearly different conceptions, so that a definition of personhood in terms of autonomy in the Kantian sense will be different from one in terms of liberal autonomy. This casts doubt on whether respect for patient autonomy in the liberal sense is an implication of respect for personhood. It is not clear why a patient’s decisions about treatment ought to be respected simply because they are based on the patient’s own (non-moral) values. There is a further difficulty. ‘Autonomy’, in the liberal conception, seems to be equivalent to ‘decisionmaking competence’. The elements of this are said to be: 1. The capacity to understand; 2. The capacity to reason; and 3. Possession of one’s own developed structure of values. Decisionmaking competence in this sense is not found in all human beings, or in any human being all the time. For example, small children, adults with learning difficulties, and people with brain damage seem to lack all three elements, or to have them only to a limited extent. People with a serious illness may lack all three temporarily. And people with certain kinds of mental disorder may, just because of their disorder, deviate from their own normal structure of values. It seems to follow that not all human beings are fully persons worthy of respect in the liberal sense of
E-mail address: [email protected] http://dx.doi.org/10.1016/j.jemep.2016.10.007 2352-5525/© 2016 Elsevier Masson SAS. All rights reserved.
Personhood and autonomy
491 personhood. This has morally undesirable implications, which suggests problems in the liberal conceptions both of personhood and of respect. It is argued that a satisfactory conception of personhood can be arrived at only by considering the use of terms such as ‘person’ in everyday, non-technical, contexts. It is argued that ‘person’, in such contexts, is almost synonymous with ‘human being’, though with particular reference to the non-biological characteristics of human beings — those in virtue of which we recognize each other as fellow-humans (as ‘one of us’). A human being does not necessarily possess decision-making competence as defined above: so respect for persons cannot depend on such competence, or require us always to accept a person’s own presently expressed decisions about what is best for themselves. It does, however, require us to recognize others as separate selves, with interests of their own, which may differ from ours. A doctor is therefore morally required to give the patient’s interests priority over his or her own, or those of the health care system. If doctors consider the patient’s expressed decision about treatment to be not in the patient’s own interests, they are morally required to engage in dialogue with the patient, in an effort to arrive at a decision which will be acceptable both to the doctor and to the patient. If the patient is unable to engage in such dialogue, because of impaired decision-making competence, then other methods of establishing the patient’s interests must be tried: examples would be proxy decision-making, by someone who is close enough to the patient to be aware of, and concerned for, the patient’s interests; or appeal to the patient’s own advance directives, where available. The most difficult case is that of patients with certain kinds of mental disorder, where the patient’s own sense of his or her interests has become distorted by the very disorder which needs treatment. Only by following an appropriate course of treatment, which the patient may currently reject, is it possible to restore the patient to a condition in which he or she can genuinely engage in dialogue. This, it is argued, makes it morally justifiable in such cases simply to override the patient’s expressed wishes. © 2016 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Éthique médicale libérale ; Autonomie ; Respect
Résumé Cet article s’interroge sur un principe central de l’éthique médicale moderne libérale : celle du respect de l’autonomie du patient. Ce principe est généralement perc ¸u comme découlant d’une exigence éthique fondamentale du respect de l’identité individuelle, laquelle reconnaît l’autonomie de l’être rationnel. Dans le domaine de l’éthique médicale, cette exigence suppose que les patients, en tant que personnes, sont en droit de prendre des décisions concernant leurs choix d’être traités ou non. Certains soulignent que cette prémisse relève d’une utilisation incorrecte du concept kantien d’« autonomie ». Selon Kant, être autonome signifie avoir un jugement moral universel, fondé uniquement sur la raison impersonnelle. Or, au terme de l’éthique médicale libérale, l’autonomie s’exprime par la prise de décision face à des dilemmes d’ordre personnel émanant de valeurs reflétant une pensée libre et indépendante. Ainsi, les approches kantienne et de l’éthique médicale libérale illustrent des conceptions bien différentes de l’autonomie. La définition même de l’identité individuelle en termes d’autonomie au sens kantien est différente de celle de l’éthique médicale libérale. Cela émet un doute à savoir si le respect de l’autonomie du patient au sens libéral implique un respect de son identité individuelle. Par ailleurs, le fait que la décision d’un patient quant à son traitement soit respectée pour seule et unique raison qu’elle soit fondée sur ses propres valeurs et non sur la moralité reste nébuleux. De plus, la notion libérale d’« autonomie » semble correspondre à une capacité à prendre des décisions, qui comprend : 1. La capacité de comprendre ; 2. La capacité de raisonner ; 3. La possession d’une structure de valeurs personnelles développée. À cet égard, cette compétence n’est ni donnée à tous les êtres humains, ni donnée à tous moments. Notamment, les jeunes enfants, les adultes ayant des difficultés d’apprentissage et les gens ayant des lésions cérébrales ne possèdent pas ces qualités ou du moins les possèdent de fac ¸on limitée. Certains atteints d’une maladie grave peuvent voir leurs capacités affectées momentanément. D’autres, possédant un trouble mental, peuvent voir leur structure habituelle de valeurs déformée en raison de ce trouble. Par conséquent, il s’ensuit que ce n’est pas tous les êtres humains qui sont des personnes dont les choix devraient être respectés au terme de la conception libérale de l’identité individuelle. Cette idée a des répercussions morales indésirables, soulevant des problématiques entourant les notions libérales de l’identité individuelle et du respect de celle-ci. Afin qu’elle soit satisfaisante, certains
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E. Matthews soutiennent que la conceptualisation de l’identité individuelle peut être déterminée uniquement en considérant l’utilisation usuelle de termes comme « personne ». Dans ce contexte, le mot « personne » est presque synonyme d’« être humain », quoiqu’il fasse particulièrement allusion aux caractéristiques non-biologiques de ce dernier, en vertu desquelles les humains se reconnaissent entre eux (l’un des « nôtres »). Un être humain ne possède pas nécessairement la capacité de prendre des décisions telles que définies ci-haut. De ce fait, le respect de la personne ne peut ni relever de cette capacité, ni exiger que nous acceptions la décision d’une personne exprimée à un moment donné comme celle qui serait la meilleure pour elle. Cependant, le respect de la personne nous force à reconnaître les autres comme étant des êtres distincts, ayant des intérêts qui leurs sont propres et qui diffèrent des nôtres. Un médecin est alors moralement tenu de mettre de l’avant l’intérêt du patient avant son intérêt ou celui du système de santé. Toutefois, si le médecin juge que la décision qu’un patient exprime quant à son traitement n’est pas dans le meilleur intérêt de celui-ci, il est moralement obligé de s’entretenir avec lui afin d’arriver à une décision avec laquelle les deux partis seront d’accord. Si le patient n’est pas en mesure d’entretenir une telle conversation dû à son incapacité de prendre des décisions, d’autres moyens doivent être employés. Recourir à une tierce personne, qui est proche du patient, qui le connaît assez bien pour savoir et se soucier de ses intérêts et qui aurait procuration pour prendre une décision à sa place ou faire appel de ses choix advenant la présence de directives anticipées, est l’une de ces alternatives. Le cas le plus difficile est celui où les patients sont affligés d’un trouble mental particulier qui déforme leurs intérêts. Ce n’est qu’à l’aide de soins appropriés que les patients, en choix de les accepter ou de les rejeter, peuvent entretenir une conversation sincère. Selon certains, cette réalité rendrait le fait de contrecarrer la volonté du patient moralement acceptable. © 2016 Elsevier Masson SAS. Tous droits r´ eserv´ es.
Autonomy, personhood and liberal medical ethics The principle of respect for patient autonomy is central to modern medical ethics — indeed, it is almost definitive of what counts as ‘modern’. Being modern, in this context, means, above all, conceiving of the doctor—patient relation differently from the way it was seen in more traditional medicine. (In this paper, incidentally, I shall, for brevity’s sake, use the word ‘doctor’ to refer to anyone professionally involved in medical treatment). In more traditional Western medicine, doctors’ relation to their patients was seen as paternalist, that is, as doing what they (the doctors) saw as best for the patient, whether or not patients agreed with them. Patients, for their part, were supposed simply to accept the doctors’ decisions (to ‘obey doctor’s orders’, as it was sometimes, significantly, expressed). But in modern society, that kind of relation is thought to be inappropriate. Modern medical ethics is liberal, in the sense of being based on the central liberal principle of equality of respect for all persons. In the context of doctor-patient relations, that means that doctors must respect their patients as equals, and vice versa. But liberalism can also be seen as the doctrine that respect for persons is above all expressed in accepting their right to determine the course of their own lives. For liberals, that means that patients must make decisions about their own treatment, in the light of their own conceptions of what makes for well-being, even if they differ from those of the doctor, or of society in general. The principle of respect for patient autonomy expresses this. This account, however, raises a number of important, and related, questions. Most central is the question, why we should accept the autonomy principle at all. It undoubtedly has an intuitive appeal, but that must be insufficient in
such an important context as medical ethics. It surely needs a firmer foundation, in some kind of philosophical argument, which would show why this right to decide is so fundamental, and also why, nevertheless, some exceptions to the principle are generally taken to apply, even in liberal thought. The justification of these exceptions is the second question, which needs to be answered. The most notable of them, which will form the principal subject of this paper, is that of treatmentdecisions in certain kinds of mental illness. My aim will be to show that thinking about this exception, above all, requires us to come up with a different, and more realistically-based, account of the ethics of medical decision-making. In order to achieve this aim, I shall first, in the rest of this section, set out what seems to me to be the most common, if usually implicit, philosophical argument for the autonomy principle. In subsequent sections, I shall consider the alleged exceptions mentioned just now, the reasons why they are believed to be exceptions, and the differences between the case of mental illness and other cases. I hope to show that the problems arise largely from some unexamined philosophical assumptions about the nature of personhood, and so of what is meant by the duty to ‘respect persons’. Questioning these assumptions should make it possible to develop a better, and more genuinely liberal, alternative to contemporary orthodoxy in medical ethics, which should be particularly relevant to psychiatry. We should begin with Kant, because I believe that the argument, which underlies the principle of autonomy is essentially supposed to be Kantian. The very use of the Kantian term ‘autonomy’ in expressing the principle indicates that its philosophical foundation is believed to be found in Kantian ethics. In an earlier article [1], however, I argued that we need to take into account some key differences between Kant’s position in general ethics and liberalism in
Personhood and autonomy regard to medical ethics. Although all readers will be familiar with Kant’s moral philosophy, it will be helpful at this stage, I think, to set out what I take to be the relevant elements of Kant’s thought, simply in order to clarify the connection with liberal medical ethics. The most obvious common element is the belief that any ethics worthy of the name must take the distinction between ‘persons’ and ‘objects’ as central, and be founded on the principle that persons ought to be treated, in Kant’s words, as ‘ends in themselves’, as having an intrinsic value. (Objects, by contrast, have value only instrumentally, as ‘means to an end’). Thus, ‘respect for persons’ amounts to ‘respect for personhood’. It is essential therefore to clarify what is meant by ‘personhood’. For Kant, what distinguishes persons from objects is ‘autonomy’, in the sense of the capacity to reason, above all, to formulate universal moral principles. These principles are ‘universal’, in that they are based, not on the personal feelings, desires, interests, etc. of the individual who formulates them, but on criteria acceptable to all beings capable of reasoning, no matter what their individual feelings, desires and interests might be. Thus, a being of a species quite different from our own, with quite different emotions, desires and needs, but with the capacity to reason, could accept such principles [2]. Kant thus introduced the concept of autonomy in the context of an attempt to define what it is to be a moral agent. Autonomy, for him, is a property of the will, ‘by which it is a law to itself (independently of any property of the objects of volition)’[3]. Autonomy is the capacity to make strictly objective, or rational, judgements about what is, or is not, a moral duty, or at least morally permissible. We human beings, in virtue of our possession of reason, are capable of making such judgements, and, because we have free-will, of acting in the light of such judgements — acting for reasons, rather than being impelled to act by causes (emotions, inclinations, desires, etc.). It is because persons are, by definition, autonomous in this sense that they have dignity: and our autonomous will is ‘the proper object of respect’ [4]. Human beings have dignity, and deserve respect, in so far as they are persons. To make the point clearer, we should expand the argument in more detail. ‘Autonomy’ is, of course, a metaphor drawn from political thought. An ‘autonomous’ state is one which makes its own laws, independently of any other state. All rational beings, Kant argues, are both citizens and legislators of a metaphorical state, which he calls a ‘kingdom of ends’ — ‘a systematic union of various rational beings under common laws’ [5]. To be a moral agent at all is thus to be obliged to recognize other persons as other moral agents, fellow-citizens in the kingdom of ends, and therefore to be treated with the same respect that we rightly demand for ourselves as persons. Setting out Kant’s position in this detail makes clear how different it is from that of liberal medical ethics. What is common to the two positions is a conception of the capacity to make rational decisions as central to what it means to be a ‘person’; what makes them different are contrasting understandings of ‘rationality’. For Kant, with his primary concern with moral agency, to be ‘rational’ is to be free of any influence from personal, or ‘subjective’, considerations of emotion, desire, self-interest, inclination, or impulse. For the liberal medical ethicist, concerned with achieving
493 the best outcome for oneself as a patient, to be ‘rational’ is rather to make decisions based on clearly thought out conceptions of one’s own of what will achieve one’s own longer-term well-being. These conceptions must, of course, be based on one’s own understanding of what one feels, desires, considers to be in one’s own self-interest, and so on. A good illustration of the difference might be found in certain kinds of life-or-death decisions. A fairly standard case in medical ethics is a decision that might face a cancer patient about whether to agree to a particular kind of medical intervention, such as chemotherapy, which might prolong one’s life for a time, but only at the cost of suffering or distress which one might find unacceptable. The patient exercises autonomy by thinking whether it is more in line with her own conception of her well-being to have a longer life, or to avoid this kind of suffering. If the latter is more important to her, she refuses the treatment, that is, accepts the likelihood of an early death. Kant talks of a case, which is in some ways parallel, but his response to it is illuminatingly different. Suppose, he says, we think of someone who ‘feels sick of life because of a series of troubles that has grown to the point of despair’ [6]. He asks himself if it would be morally acceptable, because of this, to take his own life in order to avoid prolonging this suffering, and sees (according to Kant, at least) that to think that would be to say it was a universalisable moral principle that one should shorten one’s life when its prolongation ‘threatens more troubles than it promises agreeableness’ [7]. Since this ‘principle’ would, in Kant’s view, be selfcontradictory, in that it proposes ‘to destroy life by means of the same feeling whose destination is to impel toward the furtherance of life’, he rejects suicide, thereby exercising his autonomy. For Kant, in short, the question does not concern what would promote one’s own well-being, but what could be an objective moral principle for all rational beings. Rationality, for him, consists in thinking in universal terms, not simply in thinking clearly about one’s own best interests. When one considers these examples, it becomes obvious, I think, that the Kantian argument set out above cannot provide a basis for respecting personhood in the way required in liberal medical ethics, because it is based on a different, though superficially similar, concept of ‘personhood’. ‘Rationality’, and so ‘autonomy’, have different meanings in the two cases. In so far as a patient has autonomy in the modern sense, it is because she has the capacity to become aware of her own deepest values, and to think through the connection between them and particular forms of action or refusal of action. She is capable of reasoning in that sense, but her reasoning aims, not at discovering what is objectively true from an ethical perspective, but only at deciding what is subjectively more important to her. What she arrives at, in short, is a way of thinking about her life which is authentically her own, but even to say that is to accept that it is not ‘objective’ or ‘universal’, a requirement for all rational beings as such. Thus being ‘rational’, in this sense, does not make one a fellow-member of a kingdom of ends, and so does not qualify one as deserving to be treated with respect as an end-in-oneself by other members. There does not seem, therefore, to be any Kantian ethical basis for respect for patient autonomy.
494 Allen E. Buchanan and Dan W. Brock, in their book Deciding for Others, take it for granted that respect for a patient’s self-determination should be understood as respect for ‘a person’s interest in making significant decisions about his or her own life’ [8]. This is not, however, in itself an argument for respecting that interest. It is simply a restatement of the liberal point of view — that individual ‘authenticity’ is always a good thing. In the same vein, Becky Cox White, in her Competence to Consent, argues that autonomy is morally important ‘because autonomous persons develop moral principles to guide and evaluate behavior’ [9], and implies that it must be equally worthy of respect when it is applied to non-moral values. But this implication does not follow. It may be argued, on Kantian lines, that moral agency deserves respect, and that an action is only genuinely moral if it proceeds from principles which one has arrived at by the use of reason; but ‘non-moral values’ are only personal preferences, so that it seems to make no difference whether they are arrived at by personal reflection or by conformity to social norms. Again, the underlying assumption of the value of individual authenticity in itself is more a matter of liberal dogma than of an arguable position.
Are there exceptions to the autonomy principle? For Kant, ‘autonomy’ is a defining characteristic of a person, part of what it means to be a ‘person’. In the liberal view, which we are considering, however, ‘autonomy’ is effectively identified with self-determination, with creation by individuals of a set of (non-moral) values which are authentically one’s own. This is something which, as a matter of empirical fact, human beings cannot achieve unless they possess certain cognitive abilities — those required to make decisions about one’s own welfare, or, as it is often expressed, ‘competence’. Possession of competence is not a defining feature of human beings: it is a matter of empirical fact that some human beings have it, others do not, and that those who have it can have it to varying degrees. The self-same individual, moreover, can be competent at one time, or in one respect, but not at other times or in other respects. Thus, not all human beings can be regarded as ‘autonomous’, in the sense current in liberal medical ethics: if respect for personhood is so closely tied to the possession of autonomy (competence), then how are we to respect those who lack competence, or have it only in a diminished form? To answer this question, we need first to ask what is meant by ‘competence’, and so by its lack. Buchanan and Brock list three main requirements to be satisfied if a person is to make competent decisions, about health care or anything else. First, the person must have the capacity for understanding and communication; second, the capacity for reasoning and deliberation; and, third, ‘the individual must have a set of values or conception of the good’ [10]. Becky Cox White elaborates on the third condition. As was said earlier, she emphasizes the ‘non-moral values’, by which we make decisions about our own behaviour and the sort of treatment we desire from others. Autonomous behaviour is exhibited, she says, in two morally neutral ways:
E. Matthews • we can choose our own ‘value-structure’, that is, a set of morally-neutral principles in terms of which we can construct lives which have value for ourselves; • we can use our value-structure to make particular decisions about how to conduct our lives [11]. All three take time to develop. Newborn babies have not yet developed the relevant intellectual capacities, and so have not yet been able to formulate a value-structure. As a rule, the intellectual capacities will gradually develop as the child grows into an adolescent and then an adult; and a value-structure may emerge over that same period, though experience suggests that it will seldom be coherent, clear or systematic. It will not usually be the product of disciplined reflection on general principles, but more of haphazard intuitions about particular experiences, which the individual human being may have had. At all events, this need for development over time implies that ‘competence’ will be non-existent at birth, and will only gradually develop through infancy, childhood and youth. If lack of competence removes the need to respect competence, and a lower degree of competence implies diminished respect, then babies, children and pre-adults will be one exception to the universal duty to respect autonomy. Intellectual capacities do not only require time to develop, but in human beings they also depend on the presence of functioning brain systems of the appropriate kind: moreover, they can only continue to exist for as long as these brain systems continue to function. Another kind of exception, therefore, will be constituted by those human beings whose brains do not function in the required ways, either as a consequence of hereditary abnormalities (resulting in learning difficulties) or because of postnatal brain damage caused by injury or disease. Again, if we accept the equation of autonomy with competence, and the respect due to patients to respect for their competent decisions, then patients who lack certain kinds of brain function will not, in the liberal account of medical ethics, have a right to this kind of respect. But it is arguable that the liberal account also gets into difficulties in much more everyday cases. Fully grown adults, with normally functioning brains, may well find it difficult to arrive at a decision about treatment which is ‘authentically their own’. This may be partly or wholly because they have never formulated one of White’s ‘value-structures’, or at least not one, which is clear, systematic, and coherent. ‘How much do I want to stay alive, perhaps for only a fairly short time longer, if that can be achieved only by submitting to chemotherapy?’ is an example of a relevant question to which few ‘value-structures’ could provide a clear and useful answer. In addition, decisions of this kind often have to be made when patients are not feeling at their best because of their condition, and experience shows that that is not an easy situation in which to think clearly about the future.
Mental disorders One other kind of generally recognized exception to the principle of respect for autonomy is different in kind from those considered so far. It is the main focus of this paper, and the examples considered above are included largely for
Personhood and autonomy the sake of contrast with it. This is the case of patients with certain kinds of mental disorders. Not all generally recognized mental disorders come under this heading. Patients with agoraphobia, for instance, normally recognize that they have a problem which is causing them distress, but which could perhaps be relieved by treatment: in this way, they are in much the same situation as patients with most somatic illnesses. Some kinds of mental disorder, however, are importantly, and relevantly, different from somatic illnesses. As said above, suffering from any kind of illness can reduce one’s capacity to engage in intellectual activity, such as reasoning. People who are seriously ill because of a somatic condition often find it difficult, therefore, to think clearly about what they want to happen to them. The case with this kind of mental disorder is different: patients may be just as capable of thinking clearly about themselves, but their disorder distorts the rationality of their thinking, in the sense of the conformity of their conceptions of what is good or bad in life to criteria of reasonableness which are generally accepted, and which they themselves would accept if they were not suffering from this disorder. The effect is that they do not recognize that they are ill, and suffering, and so that they need help to alleviate that suffering. Two examples may help to illustrate this point. First, people with certain kinds of psychosis will very often fail to recognize their condition, or even vehemently deny that there is anything wrong with them. If so, they may refuse to consent to treatment, which, as others can see, would help people like them. This refusal could even be said to be quite rational from their own point of view: who, after all, would think it sensible to accept treatment for an illness they were convinced they did not have? Another, and rather different, example might be people suffering from anorexia nervosa who reject their doctors’ suggestion that they should eat, even though it is clear to those doctors (and to any other objective observer) that, unless they take this advice, they will continue drastically losing weight in a way which will be ultimately fatal. From the point of view of persons with anorexia, however, it seems plain that they are in fact overweight, so that it is not rational to engage in what they would see as excessive eating. Buchanan and Brock say in their book that one of the virtues of their analysis is that it applies equally to mental and physical illness. But they then go on to say that there are several important differences in the case of mental illness which require a separate discussion, including the fact that the illness itself ‘often, although by no means always, impairs the person’s ability to make a competent decision about his or her need for treatment’ [12]. This manner of expressing the difference seems to me to underplay its significance, and to reveal an essential problem in their definition of ‘competence’. As said earlier, that definition includes both the possession of certain basic intellectual abilities and the use of those abilities to formulate a ‘value-structure’, which will be, in the phrase I have used, ‘authentically one’s own’. Determining whether someone does, or does not, have the required intellectual abilities is relatively straightforward. If they do not, or do not have them yet, then they are not ‘competent’, and so are clearly incapable of making competent choices of treatment or non-treatment. On the other hand, deciding whether someone who clearly has
495 the intellectual capacities has used them to make a ‘competent’ decision is much more difficult, if there is any doubt about the rationality of the value-structure implied. Consider the following two examples. The first is familiar from the literature of medical ethics: it is the case of a Jehovah’s Witness (an adult) who, on religious grounds, refuses a blood-transfusion, even when medical opinion is clear that this is the only way to save her life. Nevertheless, the received opinion among ethicists is that respect for autonomy implies acceptance of this refusal. The second example is the one mentioned earlier, of a person with anorexia who refuses nutrition, even after being told that it is essential if she is to avoid a painful death. Here there would almost certainly be less of an inclination to accept her refusal. Why should there be such a difference? To most of us, it seems irrational to refuse to save one’s life in either of these situations. The difference seems to be that the Witness is presumed to have formed the beliefs on which her decision is based by her own reflection on her experience, whereas the person with anorexia decides on the basis of feelings of revulsion produced, not by her own reflection, but by the illness from which she is suffering. We can expand on this by considering a fundamental difference between mental and somatic illness which is relevant to the ethics of treatment-decisions. Somatic illness, as the very name implies, affects bodily organs and systems, preventing them from functioning efficiently to make possible species-normal life, or, in the worst cases, preventing them from functioning at all, leading to death. Reflection on its debilitating, disabling and painful effects may also lead to changes in patients’ personalities, their whole view of life and what is good or bad about it from their point of view. But it is not the disease or illness itself which causes these changes: it is the patient’s own reflections on its effects. That is because they retain a ‘self’ with all the values which they have come to accept as ‘authentically their own’ (or, if their values change, it is as a result of their own reflection on their present experiences). By contrast, the kind of mental disorder which we are considering here may well involve changes in bodily organs, most likely the brain. But what makes it a ‘mental’ disorder is that it affects the ‘self’, that is, the way one characteristically thinks and feels about the world and other people, and so the conceptions one has about what would be for one’s own best in the longer-term. It is the self, which is disordered, so that the sufferer cannot detach herself from the disorder in order to decide on treatment or non-treatment. What this implies about the question of respect for those with mental disorders can best be discussed in the final section of the paper, after the concept of personhood has been re-examined in Personhood and respect reconceived section.
Personhood and respect reconceived If respect for persons is a fundamental principle of medical (or any other) ethics, it must be because there is something about the concept of a person, which ethically requires respect. The nature of that ‘something’, moreover, will determine just what we mean by ‘respect’. In this section, I shall try to elaborate, in the light of the earlier discussion in this paper, a concept of personhood which I hope will avoid
496 the essential problems found in the principle of respect for patient autonomy. A preliminary methodological question arises: how are we to arrive at a satisfactory concept of a person? That in turn raises a further question: what do we mean by ‘satisfactory’? One way in which it could be said that the Kantian concept of personhood was unsatisfactory is that it is arrived at by entirely a priori reasoning. It is designed, not to reflect what we commonly mean by a ‘person’, but to make it easier to argue for the need to respect personhood. For Kant, as argued earlier, human beings are distinguished from the rest of nature (that is, are ‘persons’) in as much as they are rational beings, ends in themselves, beings capable of making laws for themselves which do not depend on anything empirical, such as the motives and inclinations which may happen to influence them, but only on our reason. To be rational is also to be capable of determining oneself to act, simply in rational recognition of these laws, without any causal influence from the empirical forces of human nature in general, or of one’s own particular experience. The rational will is not ‘constrained by something else to act in a certain way’ [5], but acts freely, on a ‘law’ which ‘arise[s] from his will’. That is, the rational will is autonomous, completely self-determining. To ‘respect’ a person is thus to allow, indeed to promote, his or her autonomy, or capacity for free self-determination, unconstrained by subjective interests, wishes, or desires. The autonomy principle in liberal medical ethics in effect attempts to apply this Kantian argument to cases in which decisions have to be made, not about the morality of an action, but about medical treatment and its likely consequences for the well-being of a patient (where what counts as ‘well-being’ is determined by the patient’s own conceptions). But there is clearly no analogy between the two cases. Kantian moral principles are supposed to be objective and universal, but individual conceptions of well-being are subjective and particular. The claim that my decisions must be respected just because they are mine is, as already suggested, little more than an assertion of liberal dogma: that each individual subject is an infallible authority on what counts as his or her good. That rests on a concept of personhood, which is every bit as abstract and a priori as Kant’s. A ‘more satisfactory’ concept of personhood would be one, which was more realistic, in the sense that it gave an account of what it is to be a person, which fitted better with what we actually mean by ‘person’ in more everyday contexts. In terms of philosophical methodology, this could be called a ‘Wittgensteinian’ approach, though it also could be described as ‘phenomenological’, in a broad sense of that term. In either case, the justification of this approach is that any more theoretical use of the term ‘person’ (in law or ethics, for example) must be derived from its more everyday use if it is to refer to the same beings: clearly, in any medical ethics which is to have a practical application, ‘respect for persons’ must mean ‘respect for persons as ordinarily understood’. The account of personhood which we give should also clarify just what is meant by ‘respect’ for persons. So what do we mean by a ‘person’ in everyday discourse? The term seems to be synonymous, or almost so, with ‘human being’: only a few philosophers, motivated again by the demands of their own theories, rather than those of everyday use and ordinary ethics, would deny that all human
E. Matthews beings are persons. If I say that ‘person’ is only almost synonymous with ‘human being’, it is for two main reasons. First of all, because to refer to a human being as a ‘person’ is specifically to pick out certain non-biological features of humanity (to be discussed below). Secondly, because we seem to be prepared at least to conceive of certain creatures which are not biologically human as ‘persons’ in view of their possession of these non-biological features. To conceive of the possibility of non-human persons is not necessarily, of course, to affirm that any such beings actually exist. It is relevant to say, however, that when we say that a chimpanzee, or a pet cat, is ‘almost human’, we are regarding the animal as almost a ‘person’, having some of the rights to moral respect that human beings have (the rights corresponding to those non-biological properties which we think they share to some extent with human beings). What are the ‘non-biological features’, which lead us to regard human beings as persons? The biological features are those picked out in taxonomy as defining our species. We are, for instance, mammals, with upright gait, bipeds, with opposable thumbs, and so on. For life-scientists, these are the most significant characteristics. In everyday, pretheoretical, life, however, other features are usually of primary importance. Although we may recognize a creature as a human being because of these biological features, what matters most of all to us in most cases is that he or she is ‘one of us’: a potential friend or enemy, a colleague or competitor, a good companion or a bore, maybe a sexual partner, a customer or client, a fellow-citizen of the same state or an alien, someone who shares interests with us or doesn’t, and so on. Being ‘one of us’ is being in, or being capable of being in, these kinds of relationship to ourselves, and it is in being ‘one of us’, in this sense, that a biologically human being comes to be regarded as a ‘person’. Someone is capable of being so related to us (and we to them) only in so far as they can communicate with us. That implies both that they are separate from us (separate selves) and that they can nevertheless overcome this separation at least to some extent by relating to us in this way. Each person, we might say, is a separate ‘I’, with thoughts, feelings, desires, and experiences of his or her own, but is capable of conveying those thoughts, etc. to other human persons, and even of sharing thoughts and feelings with others as parts of a ‘we’. In most adults, the normal, though not the only, means of conveying thoughts, feelings, etc. is in verbal language, which is shared by both the person communicating and the one communicated to. But there are other means of communication, used by adults some of the time, and by children more of the time (in newborn infants, all of the time). These include facial expressions, gestures, body-language, and non-linguistic sounds. These non-verbal means of communication again presuppose a shared understanding of meaning between the communicating partners. To be a person, in short, is to be an ‘I’, an individual subject, essentially capable of such communicative relations to other individual subjects. Even a newborn human baby is a person in this sense, as are people with inborn defects in brain functioning, people with brain injuries or diseases, and people with mental disorders. Their communicative ability may be limited, but they exhibit it in responding to other human beings in peculiarly ‘human’ ways, including responding to others’ responses to them. Being an ‘I’ is thus
Personhood and autonomy essentially being in communication with other selves — being ‘one of us’. We formulate our thoughts in words, which we necessarily share with others. We develop our thoughts in dialogue with others, either literally, or at least in inner ‘conversation’ with them. Our ‘value-structures’, with whatever degree of clarity and coherence they may have, are one of these ways of developing our thoughts. For each person, their conceptions of personal well-being will be specially their own, in that that they will be the result of their own reflection on their own experience; but that reflection will necessarily have taken place in the context of their relations with others, guided by shared standards. They will not be the product of a subject, standing above the fray, like Kant’s rational person. And they will be continually liable to change, in the light of changes in circumstance and of dialogue with others. What is the bearing of this on the ethics of treatmentdecisions in health care? To respect a patient as a person must be, at the very least, to regard the decision about treatment as one to be made in the best interests of the patient — not in those of the doctor, or the health care system, or the state, or any other person or institution. It is, after all, the patient’s life and well-being, which are at stake here. If, however, we take a realistic view of personhood, as outlined above, then it does not follow from this that the patient has the right to have whatever treatment seems to him or her at a particular time to be the best. As was said earlier, even normally intelligent adults are not always clear, particularly when ill or frail, about what their own interests are, or how particular treatments may affect them. At least, however, normally intelligent adults can be engaged in dialogue, with the doctor and/or with others, in an attempt to discover what is in their own interests. Respect for patients as persons then requires doctors to engage in such dialogue with patients, on a footing of equality, in which doctors can offer the benefits of their scientific expertise and clinical experience for consideration by the patient. The decision would then be, not that of the patient alone, but the outcome of this cooperation between doctor and patient. It may well be that the existential nature of many medical situations will mean that such decisions, arrived at in this way, may change the patient’s ‘value-structure’, rather than simply reflecting one which is already fixed. Not everyone, of course, is a normally intelligent adult, with functioning mental capacities. But, as argued earlier, that does not mean that such others are not persons, deserving of respect. The guiding principle in deciding on treatment must still be that whatever is done is done in their interests. The difference is only that they do not have the capacity to formulate a value-structure, or do not have it to the same extent as normally intelligent adults. They do not even have the capacity, which normally intelligent adults have to engage in dialogue with doctors in order to arrive at a decision about treatment. The answer must be, therefore, as most writers on medical ethics would agree, to refer such decisions to a proxy who can be relied on to care about the patient’s interests as much as the patient would, or, in appropriate cases, to take into account advance directives agreed to by the patient when in full possession of adult capacities. This, as I say, would be generally agreed. The difference is only that I am arguing that such reliance on proxies is not an exception to the rule of respecting
497 patients, but is itself a way of respecting patients as persons.
Respecting those with mental disorders Mental disorder, as I argued in section ‘‘Mental disorders’’, differs in important ways from somatic disease or illness. These differences have led some writers, most notably Thomas Szasz [13], to reject altogether the concept of mental disorder as an ‘illness’, requiring medical treatment. This is not the place to discuss such views, however: what is important from the present point of view is that mental disorders are, in the generally accepted view of modern culture, regarded as sources of human distress, which can, and ought to, be alleviated by medical or quasi-medical treatment. If so, the psychiatrist—patient relationship becomes one variety of doctor—patient relationship, raising similar ethical problems. Similar, but not the same. In the case of somatic illness, there may be a problem about whether the patient has, or has yet, or still has, the intellectual capacity to make decisions about his or her own treatment. This is not the problem in the case of mental disorder. People with mental disorders are as likely to have such intellectual capacity as any other adult human being: the disorder affects, not their intellect, but their view of the world, other people, and themselves. Because of this, it affects the very values, which are relevant to making decisions about their interests. Thus, a person with depression feels suicidal, not because they have reflected on the real hopelessness of their lives and decided to end it all, but because of whatever is causing their disorder. Someone with anorexia nervosa finds the idea of eating disgusting, not because she is aware of the health risks of being overweight and wishes to avoid them by dieting, but because of the disorder. The disorder consists in part of these abnormal value-judgements and the ways of perceiving the world on which they rest. Its successful treatment, therefore, must consist in large part in restoring to the patient a way of perceiving which is not so caused, which is more genuinely the person’s own. Clearly, therefore, a person with the disorder is unlikely to be able to choose appropriate treatment, however intelligent they may be. It will, in all probability, be impossible even to enter into useful dialogue with them, in order to arrive at a genuinely agreed solution. How, then, do we respect their personhood in decisionmaking? It seems that we can only do so by allowing someone else to make the decision on their behalf, as is allowed in most mental health legislation in most jurisdictions of which I am aware. This may involve imposing on patients a form of treatment, which, in their present state, they would refuse. How can this be ‘showing respect for the patient as a person’? It can only be if it is assumed, and rightly assumed, that this treatment is not chosen because the psychiatrists, or the institution, favour it, but because that is what the patient would have chosen if he or she were unaffected by this disorder. Making this assumption is, in most cases, a leap of faith, which can only be seen to be justified subsequently, when and if the patient genuinely recovers. It is reasonable, however, to say that no treatment, which makes it impossible for the patient to be
498 restored to normal decision-making capacity (for example, forms of psychosurgery) can be regarded as showing respect to the patient as a person. If all else fails, such treatments may be acceptable as alleviating the patient’s distress, but they cannot be described as respectful to personhood. It might be objected that what I have described and recommended in this paper is simply what is actually done by sensible doctors. That, however, so far from being an objection, is an endorsement of what I have said. The point of the paper is not to offer a novel account of clinical practice. It is rather to show the desirability of making the theoretical account which we give of the ethics of decision-making correspond more closely to what actually happens and to a more realistic conception of human personhood.
Disclosure of interest The author declares that he has no competing interest.
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E. Matthews [3] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 47. [4] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 46—7. [5] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 41. [6] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 31. [7] Kant I. Groundwork of the metaphysics of morals, translated by Gregor M. Cambridge/New York: Cambridge University Press; 1998. p. 32. [8] Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision-making. Cambridge/New York: Cambridge University Press; 1989. p. 36—7. [9] White BC. Competence to consent. Washington, DC: Georgetown University Press; 1994. p. 14. [10] Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision-making. Cambridge/New York: Cambridge University Press; 1989. p. 23. [11] White BC. Competence to consent. Washington, DC: Georgetown University Press; 1994. p. 15—6. [12] Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision-making. Cambridge/New York: Cambridge University Press; 1989. p. 311. [13] Szasz TS. The myth of mental illness. London: Secker and Warburg; 1962.