Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law

July 2, 2009

Since the 1960s we have moved rapidly from a "doctor knows best" society in which medical paternalism was common, towards a society that celebrates patients' rights to make informed decisions about their care. In Choosing Life, Choosing Death, Charles Foster mounts a polemic against the current fervour for respect for autonomy in medical ethics and law.

Autonomy - and the model of secular rationalist individualism that goes with it - is vulnerable to attack from two sides. From the Left, there are those who argue that the "choice agenda" impedes our ability to create the kind of systems a decent society requires. Arguably, the rise of "respect for autonomy" pushes us towards a libertarian society, in which we are so mindful of individual liberty that we neglect the common goods necessary for a good society. From the Right (as perhaps in Foster's book), the attack on autonomy is often part of a wider attack on secular Enlightenment rationalism itself.

Foster writes vigorously. We are told, for instance, that the primacy of respect for autonomy "is policed with terrifying vigour. To depart from it is dangerous. It is like standing up at a meeting of the Royal Society and announcing that you are a New Earth Creationist who thinks that Darwin got his orders directly from Satan. And so the medical ethics journals are full of detailed descriptions of and reflections on the Emperor's entirely absent clothes." While this means that individual sentences and even paragraphs are enjoyable to read, it will make the book rather frustrating for an academic audience, as Foster often seems to be more interested in scoring cheap points against excesses in the rhetoric of autonomy than in working out what would be the most plausible thing for the autonomy enthusiast to say.

Partly as a result of this, there is a lack of clarity about the central thesis of the book. In the second chapter, Foster suggests the main thesis is simply that there are other moral principles that are useful in medical ethics and law in addition to respect for patient autonomy. However, not even the most ardent of defenders of autonomy would deny this (as Foster himself admits). So the real task is figuring out how we should specify what we mean by respect for autonomy, how much weight we should give to it and in what circumstances. Unfortunately, Foster says little that is helpful here, beyond the banal claim that principles other than autonomy are relevant.

In part, Foster seems to think that he can avoid the task of hard ethical thinking about the appropriate weights of different principles by focusing on the law. For example, he excuses himself from any explicit analysis of the moral status of the foetus on the grounds that "the law up until now has shown itself wholly unwilling to grapple with ... anything approaching nuance in the realm of embryonic or foetal life". However, if you are interested in whether the law gives too much or too little weight to autonomy in questions of abortion, it is hard to see how we can adequately discuss this without examining the moral status of the foetus.

In fact, Foster does seem to presuppose a view of the moral status of the foetus - namely that the foetus at 23 weeks counts as a full person, which he holds on the basis of "intuition" and the "biological facts". Here, and in one or two other places, the book at times seems to presuppose rather than argue for the key ethical claims in question.

Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law

By Charles Foster. Hart Publishing, 216pp, £22.50. ISBN 9781841139296. Published February 2009

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