Chapter

Autonomy, dialogue, and practical rationality

Guy A.M. Widdershoven and Tineke A. Abma

in Autonomy and Mental Disorder

Published on behalf of Oxford University Press

Published in print April 2012 | ISBN: 9780199595426
Published online February 2013 | e-ISBN: 9780191754739 | DOI: http://dx.doi.org/10.1093/med/9780199595426.003.0038

Series: International Perspectives in Philosophy & Psychiatry

Autonomy, dialogue, and practical rationality

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In healthcare ethics, autonomy is often conceptualized as self-determination. A person is autonomous if he can make his own decisions regarding treatment and care. Autonomy can be limited because of external or internal factors. A crucial external factor is the attitude of healthcare providers. If a provider takes over the decision (acts paternalistically), autonomy is compromised (this may be for good reasons, but nevertheless). An internal factor hindering autonomy may be a lack of decision-making capacity in the patient. If the patient is unable to express a decision (either directly or, for instance, through an advance directive), there is no room for self-determination. If the patient is unable to base the decision on adequate information and reasoning, self-determination is problematic, since decisions are not well founded. If a patient would decide between treatment options through throwing a dice, this would not be regarded as an autonomous decision, unless the options would be in all aspects equivalent, and leaving it up to chance would therefore be a reasonable way to come to a conclusion.

In this chapter, we will propose an alternative approach to autonomy, focusing not on self-determination, but on moral development as dialogical and practical learning. From this perspective, a person is autonomous if he knows the right thing to do in his situation. We will argue that this does not require freedom from external interference, but support from others who may help the person to find out what is right for him through dialogue and deliberation. If a healthcare provider questions the views of the patient, this does not necessarily imply that autonomy is compromised. By urging the patient to reflect on his values, a healthcare provider may help the patient to develop a new and better understanding of his situation and a more adequate way of dealing with it. This alternative view on autonomy entails a different conceptualization of capacity. The focus is not on the ability of making individual decisions, but on the ability of finding ways of practically dealing with one’s situation. A person who is unable to express a decision may be able to know what is good in a practical way; on the other hand, a person who is able to express what he wants to be done, does not necessarily know how to handle his situation. If capacity is regarded as being able to manage one’s situation, the emphasis is not on understanding information and being able to reason, but on insight, or practical rationality (phronesis). A person does not have to be able to reason about options in a logically coherent way, but should be able to know the right way to live in the specific situation and to realize this in practice.

We will elucidate the importance of dialogue and practical rationality with an example from forensic psychiatry. In this setting, patients are not free to refuse treatment. Yet, they do have some choices. How can professionals respect patient autonomy in this situation? From the perspective of autonomy as self-determination, one should leave decisions to the person himself, unless this would lead to danger for the person or for others involved. From the perspective of autonomy as moral development, one should support the person in giving meaning to his life and handling his situation. This implies that one does not take the wishes and decisions of the person for granted as expressions of autonomy, but sees them as a starting point for a joint process of deliberation and practical experimentation, aimed at developing autonomy in daily life.

Chapter.  6009 words. 

Subjects: Psychiatry

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