Transcript Moral Roots and Future Goals of Prenatal Diagnosis

Promotion of Autonomy as a
Goal of Medicine
Prospects and Problems
Christian Munthe
Department of Philosophy,
Gothenburg University
The Goals of Medicine:
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Positive values
Define what makes health care better –
towards what ends medicine should strive.
Basis for determination of what medical
procedures to offer, in what form, mode of
distribution, etc.
Complemented by ethical restrictions.
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Traditional candidates (not so controversial):
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Relieving of suffering (promotion of well-being)
 Prolongation of life (prevention of death)
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New Candidate:
Promotion of Autonomy
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Reason of emergence:
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Typical areas of use (so far):
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Genetic testing
Assisted reproduction
Public health medicine
Ideological roots:
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Medical procedures that are in demand but cannot be shown to
promote traditional goals
Traditional ethical restriction to respect autonomy
Consequentialist models of ’goal theories’
I.e.: an ’unholy union’, smelling of ad hoc…
…that may nevertheless be defensible!
Basics of the Idea
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Autonomy is a matter of degree:
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P is autonomous to the degree that P’s life at its various stages is
in accordance with P’s basic wants/desires/plans at these stages.
Degree of autonomy is a determinant of ’well-being’:
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Ceteris paribus, the more autonomous is P, the better is P’s life,
and the less autonomous is P, the worse is P’s life.
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Can conflict with other such determinants.
Can be aggregated and compared over indivuals.
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Not to be confused with ”preferentialism”.
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Only ’now-for-now’ and ’then-for-then’ preferences
Only ’basic’ wants
No requirement of information, rationality etc.
Can be the subject of variable normative restrictions
and/or recommendations.
Why even consider it?
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Surrender to reality…(???)
Basic moral–axiological intuition:
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The ’priority of liberty’ type of argument:
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At least a part of the good life is to lack reason to complain about
it through its various shifts.
Frustration of basic wants is a reason for complaint.
When sufficient material welfare is secured, the ability to
determine one’s own destiny becomes a priority.
The more health care masters acute threats to life and limb, the
more important it becomes to gain control of the life thus gained.
The argument from respect-theories:
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If we have reason to refrain from restricting autonomy, we have at
least some reason to promote autonomy.
Not to promote autonomy is morally equivalent to restricting it.
Denying the moral relevance of the doing-allowing distinction.
Theoretical Problems
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The ’metric’ of degrees of autonomy
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What weight should be given to autonomy as compared
to other goals of medicine?
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Is it construable? (YES! The problem is normative, not technical)
Can a normatively satisfying metric justify sufficiently precise
interpersonal comparisons?
Life – autonomy
Well-being – autonomy
Intrapersonal – interpersonal
The goal structure of medicine might ’turn organic’.
A battery of ’hard cases’ needed for further thought.
If autonomy promotions can be traded off against other
values, can the restriction to respect autonomy still be
rigidly upheld?
Practical Problems 1
Metrics and comparisons once more
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Giving autonomy a place in quality of life
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Normative puzzles
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Must give autonomy a place in QUALY-type measures.
Must give autonomy a place in cost-effectiveness measures.
Must give autonomy a place in prioritarization schemes.
’How many pounds of silver for an ounce of autonomy?’
How resolve interpersonal autonomy conflicts?
If the goal structure ’turns organic’, practical problems multiply.
But autonomy is no carte blanche for distribution according to
demand.
Practical Problems 2
What becomes of professional responsibility?
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People’s wants are expressed in health care demand
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Demand may be a reason for offering a procedure.
Demand may tip the scale so that risks are balanced by sufficient
potential benefits.
Procedures that would otherwise have been considered
irresponsible to offer, suddenly becomes responsible
Can health care professionals still be justified to resist the
offering of procedures in demand?
Can autonomy be a reason for resisting meeting a demand?
Autonomous life ≠ a life filled with free choice
Still unclear in what situations we have good reason for
restricting free choice for the sake of autonomy.