Samuel J. Ujewe Bioethics Centre, University of Otago Dunedin, New Zealand Visiting Scholar

1. Australasian Association of Bioethics and Health Law Conference, 12-14 July 2012, Viaduct Centre, Auckland“Ought-onomy: A Critique of Formalised Theories of Bioethical Autonomy” Samuel J. Ujewe Bioethics Centre, University of Otago Dunedin, New Zealand Visiting Scholar The Nathaniel Centre The New Zealand Catholic Bioethics Centre Wellington, New Zealand

2. Case : In 2002 in Christchurch, New Zealand, a young disabled couple was found dead in their home. The New Zealand Press Association reports that Debra Morris and Keith Morris were discovered ten days after they were last seen by family. Police said it appeared Mr Morris who suffered from severe epilepsy had a fatal seizure soon after putting his wheelchair bound wife to bed. Mrs Morris, who had cerebral palsy, lay in her bed unable to move or call for help until she too eventually died. A neighbour had earlier pleaded with the council to install an emergency alarm in their house to alert others after an incident where Keith had an epileptic fit and lay against the heater, burning his hand, and Debra could not do anything. However, the couple refused, as they took obvious pleasure in their independence. (Otago Daily Times)

3. Autonomy makes sense as a universal health care principle only to the extent that it appeals across the board without inherent contradiction

4. Conditions for a Viable Theory of Autonomy Universalizability: enables conceptual appreciation of the notion as a principle beyond a specific socio- cultural boundary or circumstantial condition. Practicability: grounds autonomy as applicable in real life experience Coherence: establishes mutual complementarity in the conception and practice of the notion.

5. To the extent that these conditions are granted concurrently in any conception of autonomy, it would be viable as a universal principle.

6. Formalised Theories of Bioethical Autonomy

7. Three basic formulations: Self-rule: freedom of choice, non-interference or self-assertion, and is interchanged with dignity, integrity, individuality, independence, responsibility and self-knowledge (G. Dworkin) Free Will: grounds autonomy in the right to self-determination; emphasises the area of control that one has, stresses the inner process by which decisions come about Rational Will/Agency: autonomous action is one emanating from endorsement through critical self-reflection, involving an agent’s sense of engagement or identification with his preferences or desires (N. Stoljar)

8. J.S. Mill and Autonomy as Self-Rule “The sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection… His own good, either physical or moral, is not sufficient warrant. He cannot rightfully be compelled to do or forebear because it will be better for him to do so… In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign” (Mill)  conceptually intelligible, but not practicable in human society  Given that humans are largely interdependent and no person’s activity is so completely private as never to obstruct the lives of others in any way, liberty as such is not tenable in a human society, for ‘freedom for the pike is death for the minnows’. (I. Berlin) We cannot conceive of individuals in a society living without any involuntary ties at all, unbound, and utterly free; a society of self-fashioning individuals is necessarily self-defeating (M. Walzer) Thus presented, autonomy is only a conceptual ideal of self-creation (J. Raz)

9. J. Katz and Autonomy as Free Will • Psychological autonomy entails solely the capacity of a person to exercise the right to self-determination, which involves the capacity to reflect about contemplated choices and to make choices; includes the capacity of a person to reflect, choose and act with an awareness of the internal and external influences and reasons that they would wish to accept (Katz) •  The awareness process is central • Severs relations of trust, which are a valuable component of societal harmony (O. O’Neill) – • short of universal practicability.

10. I. Kant and Autonomy as Rational Will Only a rational being has the power to act in accordance with his idea of laws – that is, in accordance with principles – and only so has he a will. Since reason is required in order to derive actions from laws, the will is nothing but practical reason (Kant) “Autonomy of the will – the good will - is the property the will has of being a law to itself, independently of every property belonging to the object of volition” (Kant) Its abstraction from free will makes it a conceptually realisable ideal – universalizable The fluid structure in practice makes for incoherence with its universalizability Only the good will is capable of being fully autonomous; the individual’s will can only be a good will and hence autonomous if untainted by inclinations (Kant) Autonomy as a matter of degrees; not a reliable as a practical principle (K. Appiah, R. Lindley)

11. Ought-onomy as the Relevant Alternative Principle The absence of autonomy does not necessarily entail medical paternalism Ought-onomy derives from the Kantian ought against the background of the human condition, as acknowledged by Katz The ought-onomous person is prompted by the ought in his choices and actions; yet at the same time influenced by the nature of the human condition What the ought-onomous person chooses may not always be a rational choice, but should always represent what the person wills or how he wills it, in relation to his socio-cultural reality and spacio-temporal circumstances. Whether in individualistic or communitarian societies, ought-onomy compels equally in people’s choices and actions

12. Patientought-onomy is the relevant principle to adopt in health care universally