The Obsteiary View Of Autonomy
Autonomy is the concept that an individual has the right to be his or her own person in the sense that all actions or decisions that are self-regarding are made solely by that person—based on his or her ideas and values. Under autonomy, not only does a person have the right to make his or her own decisions that reflect how they choose to live their life, but they also have the right to choose how they want to attain them. The idea of autonomy assumes that all individuals have the rational capacity, or in other words, the competence to make self-regarding decisions. I believe this brings about a really important debate regarding which factors or conditions deem a person rational, or competent and how this affects their right to exercise their
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autonomy. What happens when an individual has suffered through an accident or disease that has left them permanently demented and therefore has eliminated their mental faculties to reason? In “Life Past Reason” Ronald Dworkin addresses this question. In this essay I will define Dworkin’s take on the relationship between competence and autonomy. I will discuss the integrity view and evidentiary view of autonomy as Dworkin defines them. Then I will discuss how he presents them in the context of a discussion of whether doctors should comply with a mentally ill person’s advance directive to stop giving them treatment. I will discuss why Dworkin thinks the integrity view is preferable. Lastly, I will provide an objection to Dworkin’s ideas presented by Rebecca Dresser. Dworkin concentrates on mental disease as being one of the primary eliminating factors of an individual’s capacity to reason. Dworkin argues that an individual’s capacity to make self-regarding rational decisions should be based on an individual’s level of mental competence. He defines an incompetent person as one “…having all together lost the power to appreciate and engage in reasoning and argument, and cannot possibly know what is in their own best interests…” (Dworkin 359) Therefore, he believes that a person with severe mental deficits, specifically a person with late-stage Alzheimer’s (Dementia), is not competent. Dworkin argues that on one hand there is the competent person—before dementia—capable of exercising his or her autonomy, and on the other hand there is the person after dementia that is incompetent and does not have the right to exercise his or her autonomy. Evidently, Dworkin sees two facets to a person as far as mental illness is concerned and, as previously mentioned, assesses their right to exercise their autonomy based on their level of competence. This being said, I will now explain Dworkin’s take on how to approach advance directives taking into account his argument of competence in relation to two ways in which he classifies autonomy.
In terms of the life of a patient with dementia Dworkin asks, “Should what is done for him then be in his contemporary best interests to make the rest of his life as pleasant and comfortable as possible, or in the best interests of the person he has been?” (Dworkin 359) I believe Dworkin’s argument concerning advance directives is based on this question. Dworkin’s proposal on how advance directives should be approached relies on the two ways in which he classifies autonomy: the integrity view of autonomy and the evidentiary view of autonomy. The integrity view of autonomy focuses more on the value of the decisions a person makes and how they affect his or her integrity rather than how it affects their welfare (Dworkin 360). This entails respecting the decisions a competent individual chooses to make, even though these decisions may not be in his or her best interest, because they are valuable in establishing the individual’s distinctive character and fulfilling the individual’s personal wishes and desires. For example, a competent adult that smokes may be completely aware that it is not in their best health interests to smoke. However, the smoker may feel that the personal benefit they gain from smoking outweighs any possible negative effects on their health. In this sense, the smoker’s decision to smoke derives from the capacity to express his or her character through the life that the he or she leads – based on values, commitments, convictions and critical as well as experiential interests (Alzheimer’s Europe). Although the integrity view of autonomy suggests that integrity is more valuable over welfare this does not mean that making decisions that are not in the best interest of an individual are encouraged simply to establish one’s own character. Also it does not imply that all individuals, under the integrity view, make “perfect” decisions and/or live perfect lives, “the integrity view of autonomy does not assume that competent people have consistent values or always make consistent choices, or that they always lead structured, reflective lives.” (Dworkin 360) However, it encourages an individual to choose the direction of his or life and aims at building a distinctive character from all choices both rich and poor.
The evidentiary view of autonomy states that an individual’s decisions should be respected without interference, even if these decisions are not in the individual’s best interest, because the individual does it in fact know what is in his or her best interest and therefore what is best for his or her welfare. The evidentiary view and integrity view therefore differ on one main premise: the reason behind respecting a person’s autonomy. The integrity view says an individual’s autonomy should be respected based on conserving the value of an individual’s integrity and the evidentiary view says an individual’s autonomy should be respected just based on the fact that they know what is best for them. I believe the integrity view strongly values a person’s critical interests. Critical interests, as Dworkin defines them, are ones which if not satisfied, people would think they were worse off in some way or that their life had been wasted (Alzheimer’s Europe). Contrary to the integrity view, the evidentiary view is more flexible to changes in critical interests since it suggests that a person in general, at any point in their life, know what is best for him or herself and therefore acknowledges that critical interests can and will be subjected to change.
In relevance to advance directives, under the evidentiary view of autonomy, Dworkin would suggest that the treating physician of a patient with dementia not comply with the advanced directive instructing to stop treatment.
The evidentiary view supports the idea that, “people are not the best judges of what their own best interests would be under circumstances they have never encountered and in which their preferences and desires may drastically have changed.” (Dworkin 361) A person before developing dementia has no idea what it will be like, so in the case that an advance directive was written, the evidentiary view allows for the acceptance of, essentially, a change of heart. I believe the evidentiary view protects a person’s autonomy under any situation simply because, as previously mentioned, it does not hold a person accountable strictly to their critical interests, it also leaves room for and respects their experiential interests. If the integrity view is accepted, Dworkin suggests that an advanced directive to stop treatment should be complied. The integrity view suggests that an advanced directive is the only true reflection of a, now incompetent, demented individual’s competent self. Therefore, it should be respected. Dworkin claims that, “…if we accept the integrity view, we will be drawn to the view that past wishes [of a patient with dementia] must be respected.” As previously mentioned, Dworkin believes patients with dementia are not competent enough anymore to make their own decisions, especially life-altering decisions; consequently, he argues that to conserve their integrity and respect their autonomy, the advance directive should be respected. Dworkin concludes, “We might have other good reasons for treating [a patient with dementia] as he or she now wishes, rather than as, in my imaginary case, he or she once asked. But still, that violates rather than respects her autonomy.” (Dworkin
362)
Through Dworkin’s ideas, it is evident that he is in favor of the integrity view. He believes that the integrity view allows a competent person to live their life in accordance to how they want it to play out; a person is the creator of his individuality and his values through the decision he or she makes. The integrity view allows an individual to make choices that support self-creation and that make an individual’s life their own- different from the lives of others. He believes the integrity view, “…allows us to lead our own lives rather than be led along them, so that each of us can be, to the extent a scheme of rights can make this possible, what we have made of ourselves.” (Dworkin 360) To Dworkin this is the best form of autonomy that helps a person establish their true identity, as they would like it to be, through the decisions they make. In “Dworkin on Dementia” Rebecca Dresser primarily objects to Dworkin's differentiation between experiential and critical interests and their relation to autonomy on the grounds that it is possible that people sometimes do not draw a sharp line between these interests. Dresser argues that Dworkin does not take into consideration that at times, critical interests become less important and experiential interests more important, especially in situations involving people who are brain damaged or intellectually disabled. Dresser states that people, who seem happy although they may be suffering from dementia, will experience clear harm from a decision that appears to advance the critical interests that they may no longer desire. Also, Dresser disagrees with Dworkin's view on competence. She believes that just because people with demenita are not as "competent" as other people, does not mean that they should essentially lose their rights and not be protected by the law or by the moral community, even if it means being protected from their own wishes, such as in an advance directive. I strongly agree with Dresser. An advanced directive should not be a death sentence to a person who may no longer want to have his or her advance directive complied to stop treatment. If a person cannot competently decide whether the advance directive should be followed and in their state of dementia seem peaceful and seem to enjoy their life, than I believe no action should be taken. This might completely contradict the integrity view of autonomy and therefore Dworkin but if the demented person seems to be living a fulfilling life where they seem happy then I agree with Dresser and believe that they should be protected from their own directive. For this reason I am also in complete agreement with the evidentiary view. People do not know what lies ahead in the future and even though they might think they know how they are going to feel in a situation, the reality is always different than what is assumed. There should always be the option for experiential interests to prevail and they should be respected just as much as critical interests are.
I believe Dworkin would reply to Dresser’s objection that doctors should honor advance directives by first defending the integrity view of autonomy. He would say that it does not by any means require doctors to supersede a competent person's present values in favor of the person's past values. Instead, respect for integrity requires doctors to honor the patient’s past values, such as the refusal of treatment, if the person is mentally unable to make a competent decision now (Hughes). Dworkin would not consider the experiential interests of a patient with dementia because in his opinion a person with dementia has no idea what is in his or her best interest. Because of this, he would insist that either an advance directive should rule the course of their life or, if the patient did not make an advance directive, than other competent adults such as guardians and doctors should be in charge of their decisions. I believe that because Dworkin feels so strongly about his argument concerning competence and its affect on autonomy, by no means would he agree with any of Dresser’s objections and he would succeed in his response to her objection.
autonomy. What happens when an individual has suffered through an accident or disease that has left them permanently demented and therefore has eliminated their mental faculties to reason? In “Life Past Reason” Ronald Dworkin addresses this question. In this essay I will define Dworkin’s take on the relationship between competence and autonomy. I will discuss the integrity view and evidentiary view of autonomy as Dworkin defines them. Then I will discuss how he presents them in the context of a discussion of whether doctors should comply with a mentally ill person’s advance directive to stop giving them treatment. I will discuss why Dworkin thinks the integrity view is preferable. Lastly, I will provide an objection to Dworkin’s ideas presented by Rebecca Dresser. Dworkin concentrates on mental disease as being one of the primary eliminating factors of an individual’s capacity to reason. Dworkin argues that an individual’s capacity to make self-regarding rational decisions should be based on an individual’s level of mental competence. He defines an incompetent person as one “…having all together lost the power to appreciate and engage in reasoning and argument, and cannot possibly know what is in their own best interests…” (Dworkin 359) Therefore, he believes that a person with severe mental deficits, specifically a person with late-stage Alzheimer’s (Dementia), is not competent. Dworkin argues that on one hand there is the competent person—before dementia—capable of exercising his or her autonomy, and on the other hand there is the person after dementia that is incompetent and does not have the right to exercise his or her autonomy. Evidently, Dworkin sees two facets to a person as far as mental illness is concerned and, as previously mentioned, assesses their right to exercise their autonomy based on their level of competence. This being said, I will now explain Dworkin’s take on how to approach advance directives taking into account his argument of competence in relation to two ways in which he classifies autonomy.
In terms of the life of a patient with dementia Dworkin asks, “Should what is done for him then be in his contemporary best interests to make the rest of his life as pleasant and comfortable as possible, or in the best interests of the person he has been?” (Dworkin 359) I believe Dworkin’s argument concerning advance directives is based on this question. Dworkin’s proposal on how advance directives should be approached relies on the two ways in which he classifies autonomy: the integrity view of autonomy and the evidentiary view of autonomy. The integrity view of autonomy focuses more on the value of the decisions a person makes and how they affect his or her integrity rather than how it affects their welfare (Dworkin 360). This entails respecting the decisions a competent individual chooses to make, even though these decisions may not be in his or her best interest, because they are valuable in establishing the individual’s distinctive character and fulfilling the individual’s personal wishes and desires. For example, a competent adult that smokes may be completely aware that it is not in their best health interests to smoke. However, the smoker may feel that the personal benefit they gain from smoking outweighs any possible negative effects on their health. In this sense, the smoker’s decision to smoke derives from the capacity to express his or her character through the life that the he or she leads – based on values, commitments, convictions and critical as well as experiential interests (Alzheimer’s Europe). Although the integrity view of autonomy suggests that integrity is more valuable over welfare this does not mean that making decisions that are not in the best interest of an individual are encouraged simply to establish one’s own character. Also it does not imply that all individuals, under the integrity view, make “perfect” decisions and/or live perfect lives, “the integrity view of autonomy does not assume that competent people have consistent values or always make consistent choices, or that they always lead structured, reflective lives.” (Dworkin 360) However, it encourages an individual to choose the direction of his or life and aims at building a distinctive character from all choices both rich and poor.
The evidentiary view of autonomy states that an individual’s decisions should be respected without interference, even if these decisions are not in the individual’s best interest, because the individual does it in fact know what is in his or her best interest and therefore what is best for his or her welfare. The evidentiary view and integrity view therefore differ on one main premise: the reason behind respecting a person’s autonomy. The integrity view says an individual’s autonomy should be respected based on conserving the value of an individual’s integrity and the evidentiary view says an individual’s autonomy should be respected just based on the fact that they know what is best for them. I believe the integrity view strongly values a person’s critical interests. Critical interests, as Dworkin defines them, are ones which if not satisfied, people would think they were worse off in some way or that their life had been wasted (Alzheimer’s Europe). Contrary to the integrity view, the evidentiary view is more flexible to changes in critical interests since it suggests that a person in general, at any point in their life, know what is best for him or herself and therefore acknowledges that critical interests can and will be subjected to change.
In relevance to advance directives, under the evidentiary view of autonomy, Dworkin would suggest that the treating physician of a patient with dementia not comply with the advanced directive instructing to stop treatment.
The evidentiary view supports the idea that, “people are not the best judges of what their own best interests would be under circumstances they have never encountered and in which their preferences and desires may drastically have changed.” (Dworkin 361) A person before developing dementia has no idea what it will be like, so in the case that an advance directive was written, the evidentiary view allows for the acceptance of, essentially, a change of heart. I believe the evidentiary view protects a person’s autonomy under any situation simply because, as previously mentioned, it does not hold a person accountable strictly to their critical interests, it also leaves room for and respects their experiential interests. If the integrity view is accepted, Dworkin suggests that an advanced directive to stop treatment should be complied. The integrity view suggests that an advanced directive is the only true reflection of a, now incompetent, demented individual’s competent self. Therefore, it should be respected. Dworkin claims that, “…if we accept the integrity view, we will be drawn to the view that past wishes [of a patient with dementia] must be respected.” As previously mentioned, Dworkin believes patients with dementia are not competent enough anymore to make their own decisions, especially life-altering decisions; consequently, he argues that to conserve their integrity and respect their autonomy, the advance directive should be respected. Dworkin concludes, “We might have other good reasons for treating [a patient with dementia] as he or she now wishes, rather than as, in my imaginary case, he or she once asked. But still, that violates rather than respects her autonomy.” (Dworkin
362)
Through Dworkin’s ideas, it is evident that he is in favor of the integrity view. He believes that the integrity view allows a competent person to live their life in accordance to how they want it to play out; a person is the creator of his individuality and his values through the decision he or she makes. The integrity view allows an individual to make choices that support self-creation and that make an individual’s life their own- different from the lives of others. He believes the integrity view, “…allows us to lead our own lives rather than be led along them, so that each of us can be, to the extent a scheme of rights can make this possible, what we have made of ourselves.” (Dworkin 360) To Dworkin this is the best form of autonomy that helps a person establish their true identity, as they would like it to be, through the decisions they make. In “Dworkin on Dementia” Rebecca Dresser primarily objects to Dworkin's differentiation between experiential and critical interests and their relation to autonomy on the grounds that it is possible that people sometimes do not draw a sharp line between these interests. Dresser argues that Dworkin does not take into consideration that at times, critical interests become less important and experiential interests more important, especially in situations involving people who are brain damaged or intellectually disabled. Dresser states that people, who seem happy although they may be suffering from dementia, will experience clear harm from a decision that appears to advance the critical interests that they may no longer desire. Also, Dresser disagrees with Dworkin's view on competence. She believes that just because people with demenita are not as "competent" as other people, does not mean that they should essentially lose their rights and not be protected by the law or by the moral community, even if it means being protected from their own wishes, such as in an advance directive. I strongly agree with Dresser. An advanced directive should not be a death sentence to a person who may no longer want to have his or her advance directive complied to stop treatment. If a person cannot competently decide whether the advance directive should be followed and in their state of dementia seem peaceful and seem to enjoy their life, than I believe no action should be taken. This might completely contradict the integrity view of autonomy and therefore Dworkin but if the demented person seems to be living a fulfilling life where they seem happy then I agree with Dresser and believe that they should be protected from their own directive. For this reason I am also in complete agreement with the evidentiary view. People do not know what lies ahead in the future and even though they might think they know how they are going to feel in a situation, the reality is always different than what is assumed. There should always be the option for experiential interests to prevail and they should be respected just as much as critical interests are.
I believe Dworkin would reply to Dresser’s objection that doctors should honor advance directives by first defending the integrity view of autonomy. He would say that it does not by any means require doctors to supersede a competent person's present values in favor of the person's past values. Instead, respect for integrity requires doctors to honor the patient’s past values, such as the refusal of treatment, if the person is mentally unable to make a competent decision now (Hughes). Dworkin would not consider the experiential interests of a patient with dementia because in his opinion a person with dementia has no idea what is in his or her best interest. Because of this, he would insist that either an advance directive should rule the course of their life or, if the patient did not make an advance directive, than other competent adults such as guardians and doctors should be in charge of their decisions. I believe that because Dworkin feels so strongly about his argument concerning competence and its affect on autonomy, by no means would he agree with any of Dresser’s objections and he would succeed in his response to her objection.