AUTONOMY

The concept of autonomy in moral philosophy and bioethics recognizes the human capacity for self-determination, and puts forward a principle that the autonomy of persons ought to be respected. At this level of generality, there is not much with which to take issue; a full account of autonomy must further define self-determination and state how and to what extent autonomy should be respected. Autonomy as a capacity of persons must be distinguished from autonomy as a property of actions and decisions, for a person with the capacity for autonomy may act nonautonomously on particular occasions, for example, a person who is coerced to do something. Autonomy as a fundamental value and a basic right is part of the moral and political theory of liberal individualism. According to this view, autonomous individuals are the ultimate source of value: The basis for an action, social practice, or government policy to be right or good is in the values, preferences, or choices of autonomous individuals. In social philosophy, individual autonomy as a basic value and a fundamental right is in tension with community values, such as caring for others, promoting the good of society, and preserving and enhancing the moral practices of society. In clinical bioethics, the right to autonomy of individual patients is in tension with healthcare professionals' obligations to benefit patients. These conflicts will be examined in what follows.

Autonomy as Capacity

There are three elements to the psychological capacity of autonomy: agency, independence, and rationality. Agency is awareness of oneself as having desires and intentions and of acting on them. (Desire includes inclinations, aversions, wants, and similar terms.) When people have a desire for some state of affairs, they form an intention to do what they believe will bring about the desired state of affairs; further, they want their desire to determine their action (Benn; Haworth).

The capacity for agency distinguishes persons from inanimate objects and from nonhuman animals. Inanimate objects can be affected by objects and conditions external to them, as can persons, but unlike persons, inanimate objects cannot be said to act on desires. Nonhuman animals have desires, but there is no (noncontroversial) reason to believe that they have the capacity for self-consciousness that is manifest in having an awareness of desires and wanting them to be effective in action. Agency does not imply that persons are never influenced by external forces or that persons never act impulsively. It is an account of how persons are able to act and not how they always act.

Independence is the absence of influences that so control what a person does that it cannot be said that he or she wants to do it. This may seem a feature of an autonomous action rather than an element of psychological capacity. However, there are cases in which a person's course of life is under constant threat of violence from others, and the person acts always to avoid harm: war, poverty, abusive relationships, police states. When the whole of a person's beliefs, plans, self-image, and ways of relating to others are the result of unrelenting coercion and manipulation, then that person has little or no capacity for autonomy.

Autonomy also requires that persons have an adequate range of options. Coercion and manipulation limit options, but options are also limited by social and physical environments. If a person's options are numerous and noncoerced but are trivial in relation to what is valued by the person, then there is no capacity for autonomy in a significant sense (Raz). This would be the case in a totalitarian, caste, or slave society where a combination of coercion and ideology suppress the aspirations and real options of a segment of the members of the society. A full account of the conception of autonomy must distinguish external influences that defeat autonomy from external influences that are consistent with being autonomous. The former includes coercion and manipulation, and the latter includes persuasion and the normal limitations of physical and social environments.

The third element of the capacity for autonomy is means-end rationality, or rational decision making. In addition to the self-consciousness of agency, the capacity for rational decision making requires a person: (1) whose beliefs are subject to standards of truth and evidence; (2) with ability to recognize commitments and to act on them;(3) who can construct and evaluate alternative decisions;(4) whose changes in beliefs and values can change decisions and actions; and (5) whose beliefs and values yield rankings of action commitments. Another way to understand rationality as an element of the capacity for autonomy is as the capacity for reflection on desires. A rational person can have a desire for or fear of something, such as a desire for food or a fear of surgery, and also have the wish that he or she not have that desire or not be moved by that fear (Dworkin, 1976, 1988; Childress). Persons who lack the psychological capacity for rational decision making are those who are severely mentally ill—paranoiacs, compulsive neurotics, schizophrenics, and psychopaths. Such persons have the capacity for agency, that is, they are aware of acting on their desires, but they fail to meet one or more of the above conditions. For example, a paranoid patient who persists in a delusion that the healthcare professionals are Martians attempting to capture him is unable to adjust beliefs and actions to a reality confirmed by evidence (Benn).

Principle of Respect for Autonomy

Principles that support autonomy can be directed at the everyday relationships and encounters between persons; at the constitution, laws, and regulations of a nation-state; and at the policies of institutions such as hospitals, insurance companies, schools, and corporations. What ought to be done to respect autonomy will not be the same at all these levels and will be a function of a broad social ideology.

The minimal content for a principle of respect for autonomy is that persons ought to have independence, that is, be free from coercion and other similar interferences. John Stuart Mill made this the main principle in On Liberty (1947): No one should interfere with the liberty of action of another except to prevent harm to others. This obligation not to coerce others is defensible as an obligation binding on individuals, private organizations, and governments. Mill defended his principle of liberty, not because he believed that there is a fundamental right to autonomy nor that autonomy is valuable in itself, but because the recognition of liberty is supported by the principle of utility. This principle is that an action or policy is right to the extent that it promotes the greater happiness for the greater number. However, securing negative liberty does not establish autonomy as fundamental in moral theory. Other philosophers have gone further than Mill in their defense of autonomy.

The most widely quoted principle of respect for autonomy is one of Immanuel Kant's versions of the categorical imperative: "Treat others and oneself, never merely as a means, but always at the same time as an end in himself" (p.101). This is frequently expressed as treating others as persons, and its distinctive Kantian claim is that others should be treated as rational beings who have their own ends. A further explanation of this principle is that persons should be seen as having interests in two senses. First, interests in those things that are a benefit to nearly everyone, for example, being free of pain, not being killed, being saved from dying. A physician can treat a patient without that person's consent and still protect these interests. Second, autonomous persons "take an interest" in things, that is, have preferences, projects, and plans. Acting only with concern to serve interests in the first sense, as is sometimes alleged against uses of the principle of utility, is not sufficient for respecting another's autonomy; we must also discover and take into account the individual's values and objectives (Benn). For example, a physician may believe that a surgical procedure is an effective treatment to relieve the pain of a patient's ulcer, but the patient may have a greater aversion to the risks of surgery than the physician does, and would prefer a restricted diet and medication. To not solicit, or to ignore, the patient's preferences in this matter would not respect his or her autonomy.

Autonomy, Rights, and Liberty

The concept of rights presupposes that right-holders are beings who have the capacity for autonomy, who make choices and can use discretion to exercise a right or not. Basic liberties in a liberal democracy are protected by constitutional and other legal rights. The idea of a right has three elements: the right-holder (the person who has the right); the object of the right (the activity or thing that the right-holder has a right to); and the duty-bearer (the person or institution who must do what the right requires). Negative rights are rights not to be interfered with; for example, everyone has the right not to be given medical treatment without consent, and all healthcare providers must respect this right. Positive rights are rights that a person be provided with something—for example, the right of all senior citizens in the United States to Medicare payment for healthcare, a right that is binding on government agencies and healthcare providers.

Recognizing the negative right to autonomy imposes on everyone the obligation not to coerce or otherwise interfere with the action of another. This protection of autonomy is not as costly to social institutions as recognizing positive rights to autonomy. If there is a positive right to X , this means that someone is under an obligation to provide X to the right-holder(s). For example, if every citizen has a fundamental positive right to the best-quality medical care, then the state must provide full access to medical care to all citizens. While there cannot be a positive right to autonomy per se—for autonomy as capacity is not something that can simply be given to persons who do not have it—there can be rights to other things that are required for, or supportive of, autonomy. Among them are rights to a decent minimum of healthcare, education, a decent standard of living, political participation, freedom of inquiry and expression, and equal opportunity to compete for positions in society. These goods contribute to autonomy in two ways: First, they make possible the development of the capacity for autonomy; second, they make autonomy meaningful by establishing the personal and social powers and range of options for autonomously chosen projects and plans. Discrimination against minorities and women decreases their autonomy by explicitly excluding them from desirable positions in society and by implicitly agreeing to the limited range of options offered to minorities and women.

Autonomy as an Ideal

There is no sharp line separating accounts of autonomy as an ideal from autonomy as an actual capacity of persons. Autonomy can be described as a high level of self-determination that few persons will actually achieve, and yet it can still be regarded as a capacity for all persons, if it is believed that all persons under suitable conditions could acquire it and use it to direct their lives. Views that describe autonomy at a level that nearly all normal adult persons can and do exercise are views of autonomy as capacity, and views that describe it at a higher level are accounts of autonomy as an ideal.

Autonomy as an ideal will center on a person's use of the capacity for deliberation and reflection. The person who realizes the ideal of autonomy is, first, one who is consciously aware of having the capacity, someone who believes that he or she can use it to shape his or her life. Second, the autonomous person will make particular decisions with a sense of control—creating and evaluating options. That person will also reflect on how values, preferences, attitudes, and beliefs received in the socialization process function in his or her own decision making, examine the kind of person this makes him or her, consider alternatives, and make a commitment to accept or try to alter who he or she is. This is of course a matter of degree; like every virtue, it can be realized well and thoroughly or in some small measure. The ideal of autonomy does not require individuals to make conscious, deliberated decisions before every action. A person who has accepted a set of preferences, beliefs, and attitudes can respond without much thinking to common situations that fall into recognized patterns.

Autonomy of Actions

In a clinical setting, it is often important to determine whether a patient's decision regarding treatment, or the decision of a proxy in the case of an incompetent patient, is autonomous. A person who has the capacity for autonomy may, for a variety of reasons, not act autonomously on a particular occasion. Determining whether a particular action or decision is autonomous is a matter of how the three elements of the capacity for autonomy (agency, independence, and rationality) are involved in the process of deciding. The autonomy of actions is a matter of degree because independence and rationality are matters of degree, though agency is not.

Ruth Faden and her colleagues describe the three elements of autonomy as intentionality, freedom from controlling influence, and understanding. They point out that controlling influences and understanding can be seen on two independent continua. An action can be performed within the range of full understanding to full ignorance, and within the range of completely uncontrolled to completely controlled.

Bruce Miller views the autonomy of actions and decisions on four levels: (1) as free action (agency and independence); (2) as authenticity (the decision is consistent with what is known about the person's values, preferences, and plans); (3) as effective deliberation (rationality); and (4) as moral reflection (deliberation about one's values, preferences, and plans). The decision of a patient may be autonomous at one or more, but not all levels. For example, a patient who accepts a recommended treatment without reflecting much about the decision, acted autonomously at the level of free action, and perhaps authenticity, but not at the levels of rationality and moral reflection.

The legal concept of competence is closely related to the concept of autonomy. A competent person is one who has the capacity for autonomy, and a competent decision is one that is autonomously made.

David Jackson and Stuart Youngner present six cases of decision making in an intensive-care unit that "illustrate specific situations in which superficial preoccupation with the issues of patient autonomy and death with dignity could have led to inappropriate clinical and ethical decisions …"(p. 407). In one of the cases, a patient with multiple sclerosis appeared to autonomously refuse further lifesaving treatment following a suicide attempt. However, psychiatric evaluation showed that the patient had become depressed and withdrawn at the time his wife and sons began spending time with his mother-in-law who had been diagnosed with inoperable cancer.

Jay Katz has said that insufficient attention has been given to the unconscious and irrational motivations of behavior. It is not only patients' motivations that should be examined, but physicians' as well, for example, their denial of uncertainty. Whether a patient's decision to consent to or refuse treatment is autonomous depends on more than the patient's statement of decision and reasons. Physicians and patients must engage in conversations; physicians are obligated to facilitate patients' opportunities for reflection to prevent ill-considered decisions, and patients are obligated to participate in the process of thinking about their choices. The U.S. President's Commission (1982) echoes this view in its discussion of the importance of communication between patient and health professional to attain shared decision making based on mutual trust.

Privacy, Informed Consent, and Paternalism

Autonomy as a fundamental right is used to justify rights to privacy, confidentiality, refusal of treatment, informed consent, and a decent minimum of healthcare. The legal right to privacy has two components. The right to control information about oneself is protected in medicine as the patient's right to confidentiality of information gained by health professionals. The right not to be interfered with and to make one's own decisions is protected in medicine as a competent patient's right to refuse recommended treatment and as the obligation of health professionals to obtain a patient's informed consent to treatment. Informed consent requires that a patient be informed of a recommended treatment and of the options for treatment and their likely consequences, and that the patient give express permission for a treatment (often in writing). The right to autonomy also requires that patients be told the truth about their medical status and prognosis, that their questions be answered, and that they receive assistance from healthcare providers in making rational decisions. Meaningful exercise of the right to autonomy in living requires that individuals possess physical and psychological capacities within the normal, human range. So the positive right to autonomy supports a right to a level of healthcare that will return and maintain a person to the normal range of functioning. This includes acute care, for example, repair of a broken bone; chronic care, for example, treatment of diabetes or heart disease; and supportive care for permanent disability, for example, wheelchairs for paraplegics.

Paternalism in healthcare is treating a patient against his or her wishes on the grounds that the healthcare provider is professionally obligated to provide care that will benefit patients, and that the healthcare provider knows better than the patient what is good for the patient. When paternalism is justified, it overrides patient autonomy, at least partially. An example of justified paternalism could be when a physician does not accede to a patient's refusal of emergency treatment because the patient believes he or she will surely die.

Criticisms of Autonomy

Some authors (Clements and Sider; Callahan; Thomasma) have criticized the centrality of autonomy in medical decision making. Their argument states that the primary obligation of healthcare providers is to maintain and restore health. There are two aspects to this claim. First, if patient autonomy is given primacy over the obligations of health professionals, physicians and other providers may violate their obligation to maintain and restore the health of patients; for example, a patient may refuse a treatment that will save his or her life or prevent a serious illness. These conflicts between autonomy and patient benefit have often been decided by courts, usually in the form of a request by a terminally ill patient's family member, or other agent, that life-preserving treatments such as respirators be withdrawn, a request denied by physicians who cite their obligation to preserve life.

A second aspect of the criticism of autonomy recognizes the centrality of patients' values and wishes in cases of deciding whether to forgo life-preserving treatment for a terminally ill patient, but other sorts of medical-care decisions depend less on respecting patients' rights to autonomy and more on the value of restoring and maintaining the capacity for living a meaningful life. In this sort of case, autonomy is secondary to principles of beneficence, compassion, and caring.

Defenders of autonomy can make several replies to this critique. (1) Some of the attacks on autonomy wrongly assume that it is simply a principle of negative freedom, that is, the right not to be interfered with. (2) The claim of the centrality of patient autonomy in medicine does not imply that it is the only value. The principles of beneficence or nonmaleficence may, in some circumstances, justify paternalism. (3) Autonomy cannot be ignored in medical decision making. Knowing what will be most beneficial for a patient often requires input from the patient on values, objectives, and preferences. This is true not only in morally difficult situations that call for a decision about preserving the life of a terminally ill patient, but in less dramatic cases as well, for example, whether a patient should have surgery for a condition that causes minor discomfort and dysfunction but will not develop into something more threatening to health, or whether the patient should simply "live with" the condition. In cases of acute and severe injury or illness where there is clearly a best treatment that will almost certainly restore the patient to health, it can usually be safely assumed that whatever else the patient values, he or she will value the restoration of health, and hence, discussion of the relative value of options and their consequences is not required to respect the autonomy of the patient.

Criticisms of autonomy have also been launched from a broader, communitarian perspective (MacIntyre; Sandel; Callahan). Communitarians charge that the political theory of liberal individualism states that individuals are fully self-determining and that rights to autonomy are the primary or sole standard for individual behavior, institutional practices, and government policy. Communitarians object to liberal individualism on several grounds. First, the socialization process determines, or shapes, the values and preferences of individuals, hence, the idea of autonomously chosen values is factually incorrect. Second, an individual's actions, desires, and objectives are comprehensible only within the context of social conventions and institutions. For example, a person cannot report that he or she is thinking about depositing a check without the conventions of language and the institution of banking. Third, the view that an autonomous individual chooses his or her own values, preferences, and desires presupposes a self that does the choosing. This self will have to have a core of values with which to choose, in which case either there are values not autonomously chosen, or it is inexplicable how individuals come to have a set of values. Communitarians also claim that liberal individualism regards persons as separate from others in the sense that individuals have no obligations to others or society that are not voluntarily assumed, other than the obligation to respect the individual rights of others. A society that respects only the autonomy rights of all its members is not morally complete. A good society must recognize obligations to help others; its members must have virtues such as compassion, caring, and love, and they should recognize a commitment to society to maintain social practices and institutions that establish and promote these obligations and virtues (Callahan).

There may be theories of autonomy that are susceptible to these criticisms, but the fundamental value of autonomy can be defended without embracing such versions of liberal individualism (Sher; Taylor, 1985). The conceptions of autonomy presented above recognize that persons are social beings whose values and preferences are shaped by society and that the capacity for autonomy is itself socially determined. Being autonomous requires language and reason, and these abilities are not possible without socially given practices and standards. Reflecting on socially given values and preferences and either accepting them as one's own or changing them in some measure, which is a feature of autonomous persons, cannot be done unless there is a social environment that encourages autonomy. A free society makes autonomy possible.

However, a society in which no one does more or less than respect everyone else's liberal rights, in which there is no caring, love, or friendship and no neighborhood associations, political parties, or civic groups, is not one we would want, though it may be a liberal society (Gutmann). On the other hand, a society organized to promote civic virtues and obligations such as beneficence, caring, and compassion, but which does not recognize a right of individuals to be different, to make their own decisions about matters of importance to them or to find a style of life that makes them happy, is also not one we would want. Love and care can be stifling if they do not recognize an individual's own view of what his or her good is. Finally, a defensible theory of the nature and value of individual autonomy will fall between radical individualism and extreme collectivism. It must explain the obligations to create and maintain social and political institutions that support the exercise and flourishing of autonomy. It must explain how the exercise of autonomy depends upon the opportunity range and values given in the traditions and structure of society. It will also recognize other fundamental values and explain their place in decision making.

In the early period of contemporary medical ethics, much attention was on medical paternalism in cases of life-and-death decision making for terminally ill patients and on what can be called "medical opportunism" in research on human subjects. Critics of these practices brought the rights of patients and subjects to the forefront of medical ethics. In a climate of concern for allocation of healthcare resources and other issues of social policy, autonomy appears less frequently in medical ethics literature than do moral concepts such as justice, fairness, equality, economic efficiency, and cost-containment. This shift in issues should not lead to the view that autonomy has lost its importance in moral and social theory and in bioethics.

bruce l. miller (1995)

bibliography revised

SEE ALSO: Beneficence; Coercion; Conscience; Ethics: Social and Political Theories; Freedom and Free Will; Human Dignity; Human Rights; Informed Consent; Justice; Professional-Patient Relationship; Research Policy: Subjects; Sexism

BIBLIOGRAPHY

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Thomasma, David C. 1984. "Freedom, Dependency, and the Care of the Very Old." Journal of the American Geriatrics Society 32(12): 906–914.

U.S. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1982. Making Health Care Decisions: A Report on the Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Washington, D.C.: Author.

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AUTONOMY

AUTONOMY , the religious, legal, social, and cultural self-sufficiency of the Jewish community within the sovereign non-Jewish state or its subdivision; Jewish self-government. Jewish autonomy was conditioned by both external and internal forces. By definition it did not exist during the periods of political sovereignty in the days of the Jewish independent states. During the periods of Persian and Greco-Roman subjugation the Jews enjoyed considerable self-government, especially in the form of polyteuma, an autonomous community within the Hellenistic city, as in *Alexandria. Throughout the Middle Ages, when European society generally was constituted of distinct corporate groups each with its own way of life, the Jews were also governed by their own laws and institutions. The Christian authority in the lands of Europe, whether emperor, king, pope, duke, or municipality, as well as the Muslim caliph or other ruler, granted them various privileges of serf-rule. These dealt mainly with their rights of commerce, moneylending, or litigation with Gentiles. The internal political and social life of the Jews was left inviolate. The basic Christian legal concept permitted the Jews to live according to their law (secundum legem eorum vivere). In Islam the very idea of the "People of the Book" predicated the toleration of Jews and Christians to live according to their respective sacred scriptures. The trend toward civic emancipation and the onset of the Enlightenment (*Haskalah) movement within Judaism in the 18^th century tended to curtail group autonomy in favor of the rights of the individual. The tendency was afforded external stimulus by the insistence of the modern state on the complete allegiance of its citizens, demanding the elimination of corporations. The 20^th century has seen brief experimentation with a special form of self-rule based on *minority rights, only to witness the dissolution of Jewish autonomy in its traditional form in many places. In countries with a pluralistic society, such as the United States, a new, voluntary Jewish internal leadership structure is emerging.

Throughout more than 2½ millennia powerful internal forces bolstered the Jewish autonomous institutions. Most pronounced were the religious element and national cohesion. From their law the Jews evolved a unique way of living, a regimen of holiness and pietism; the freedom to practice it was cherished above life. The messianic hope for eventual political sovereignty was never abandoned. The Jews clung to the eschatological vision of redemption from *galut ("exile") and of national revival and reunification in Ereẓ Israel. The basic institutions of Jewish self-government were developed in ancient times: the congregation, which enabled ten adult males anywhere to form a viable group; the association (see *Ḥevrah); the court of justice; and self-taxation. According to the formulation of *Saadiah b. Joseph, the Jews formed "a nation by virtue of their laws." No matter how far the Jews exerted themselves to observe the talmudic rule that "the law of the land is law" (bk 113a), they still clung tenaciously to their autonomous institutions. They also preferred physical segregation from the other religious, ethnic, and professional groups among whom they lived. Topographical isolation enabled them to enjoy the religious, educational, and social advantages of contiguous living. Moreover, the instinct for self-preservation dictated communal solidarity, a united front to face the often hostile outside world. Finally, the sense of alienation from the surrounding population engendered primary loyalty to their own community. With all the structural and functional diversity occasioned by the manifold conditions in the countries of dispersion, the autonomous Jewish community succeeded in maintaining a continuity with the past and an essential unity with far-flung Jewry.

Three main instruments of Jewish self-government have been the national or regional agency, the local community, and the association.

Centralization

When the Arabs conquered Persia in 637 c.e., they maintained there the hereditary exilarchate in its traditional glory (see *Exilarch, *Geonim, *Academies). The Jews were responsible for the collection of the poll and land taxes demanded from them by the central government. Otherwise, they were free to govern themselves. They levied taxes for internal needs, regulated imposts on ritually slaughtered meat, and appointed judges. Government of the community was aristocratic. All communal affairs were guided by the leadership strata constituted roughly of (1) a hereditary aristocracy of scholarly families, institutionalized in the academies; (2) the "Davidic" dynasty of the exilarchs; (3) from the tenth century, wealthy and influential court bankers. During most of the Islamic period, Ereẓ Israel formed a kind of center of Jewish autonomy, with geonim of its own; later, with the breakup of the caliphate, provincial leaders, such as the *nagid, made their appearance.

Medieval European society was structured into corporate groups, each governed by its own laws. Noblemen and serfs in the feudal system, burghers and guild members in the municipality, the clergy and religious orders within the church, all enjoyed some degree of autonomy. The corporate body in turn owed fealty to a more embracing power. Jews were generally under the direct protection of the monarch; they were, therefore, often exempt from obligations to intermediate powers. Christendom kept the Jews apart and in subjection to remain as visible witnesses testifying to the truth and victory of Christianity. These factors favored Jewish autonomy. The synagogues and Jewish cemeteries were protected; litigation among Jews was left to the rabbinical courts, while the community as a whole had powers of taxation, excommunication, and, in some cases, capital punishment. The greater the fiscal contribution to the state by the Jews in comparison to that of the Christian population, the more the rulers tended to rely on the Jewish autonomous organization as their fiscal agents.

Jews enjoyed considerable autonomy in the *Byzantine Empire. In Christian *Spain self-rule achieved heights rivaled only in the Muslim lands and by the Councils of the Lands of Poland-Lithuania. In order to foster strong communal cohesion, the Jewish authorities in Spain were granted wide powers to deal with informers, including the imposition of capital punishment. Jewish autonomy in Spain attained its peak in the 13^th century. In Germany, France, England, and the Netherlands the institution of the corporation was particularly developed and powerful. The Jews were increasingly placed outside the framework of Christian society, more so than in Spain. Within this political framework, and against this social and legal background, therefore, the Jewish community in Northern Europe, as in the south, acquired the status of a corporation. The individual communities were governed by a variety of privileges granted by imperial, royal, ducal, episcopal, or municipal rulers. The similar institutions in Poland and Lithuania were patterned after those of Central Europe. Early legislation was modeled on privileges granted to the Jews in neighboring Austria and Bohemia. Gradually, the Polish king expanded the autonomy granted to the Jews. Sigismund ii, for example, decreed in 1551 that any Jew who resists "the censures and bans imposed upon him by the rabbi, judge, or other Jewish elders… shall be beheaded." After a certain point in the second half of the 16^th century, Jewish autonomy in Poland-Lithuania developed in explicit recognition by the monarch of the fiscal functions of central organs and tacit acceptance of their activities in other fields as well (see *Councils of the Lands). However, in 1764 the Jewish self-governing agencies were abolished on the express order of the disintegrating Polish state.

Central Organs of Self-Rule

The European communities in medieval and early modern times did not perpetuate the hereditary exilarchate, or patriarchate, or the geonate of the earlier period. Central organs of self-rule, however, developed as a result of two factors: (1) the built-in ideological and practical endeavors of the Jews to preserve an inclusive national unity, as far as communications and the respective political framework permitted; and (2) the practice of rulers of imposing a lump sum of taxes upon the Jews of a country. Central agencies were formed in order to distribute the fiscal burden among the provinces and communities. In addition to functioning as an arm of the state, these agencies also regulated the internal affairs of their constituents.

The Jewish striving for a central, national, autonomous leadership often took the form of *synods. Recourse was also made to the personal authority of a great rabbi, such as Jacob b. Meir *Tam. In addition, institutional authority was delegated through the representatives of the leading communities and the congregation of many scholars combined in them. They usually sought some form of confirmation of their resolutions by the secular ruler. The earliest Jewish synods on record are those held by the French and Rhenish communities; they were later convened from time to time in various countries and in various periods from the Middle Ages to early modern times. The synods generally attempted to deal with the whole gamut of problems relevant at their time of meeting, even though a single central problem often seemed to dominate their deliberations. Sometimes the synods were coterminous with a national framework and boundaries (see *Bohemia-Moravia; *Aragon; *Italy); sometimes they were regional only (see *Germany). (In the modern period the synod form of communal leadership has been revived by the Jewish *Reform movement.)

The Local *Community (Heb. קְהִלָּה, kehillah)

The kehillah, the cell of Jewish societal life and leadership, was based on the concept of partnership shared by the Jews as inhabitants of a certain locality. Much as the individual Jew was affected by his national or regional autonomous institutions, he enjoyed the fruits of self-government directly only through his own local community and the various associations within it. The foundations of the local community are to be found in the early days of the Second Temple, when the congregation took root and every town had its administrative machinery. The hallmarks of community life evolved as communal prayer, charity, mutual aid, a judiciary, and the power to enforce communal decisions. The kehillah did not figure prominently in the days when the exilarchs and geonim appointed local functionaries. It came into its own again in North African and Spanish communities and in those on the Rhine in the second half of the tenth century. The kehillah acquired a legal character with the right to judge and to impose taxes. The rabbis of that age reinterpreted talmudic law in the responsa to strengthen the autonomous institutions by giving them authority over the individual.

In time, marked similarities developed in the widely scattered communities in regard to both structure and function. Nearly every kehillah possessed written takkanot, many of them of a constitutional character. There were regularly scheduled meetings of the entire membership, as well as of the elected elders to the kahal ("community board"), who were usually drawn from the aristocracy of wealth or learning. The elders were designated by a variety of titles in Hebrew or in the local vernacular. Each community was served by paid communal officials, such as the rabbi, dayyan, or preacher, who offered religious, educational, judicial, financial, and welfare services to the residents. Notwithstanding the underlying uniformity of autonomous practices in the countries of the dispersal, the councils, kehalim, and associations were not all of one cloth. In Central and Eastern Europe there was only one kahal for every local community. On the other hand, the advent of refugees from Spain in Italy, Holland, and the Ottoman Empire sometimes produced differentiation within each community on the basis of the country or city of origin, or by Sephardi or Ashkenazi descent. On the other hand, in some places the various elements, while maintaining separate religious institutions, were treated as a corporate body vis-à-vis the outside world in relations with the government.

The Association

The smallest cell of Jewish communal life was the local association (ḥevrah). Whereas the community board had powers of taxation and legal standing, the association was a voluntary membership group. Throughout the Middle Ages it was controlled by the kahal to serve the public weal. As the kahal dissolved in the Emancipation era, the association often took over its essential functions. A major characteristic of most ḥavarot was the assurance to every member that upon his death the survivors would intercede before God for his soul through prayer and study.

The four major categories of associations were (1) religious, to maintain synagogues or chapels, or for worship or mystical activities; (2) educational, for provision of school facilities for the poor, or adult study groups; (3) philanthropic, for visiting the sick, or care of paupers; and (4) vocational, mainly consisting of craft guilds. Outstanding among the philanthropic associations was the burial society, *ḥevrah kaddisha gomelei ḥasadim, which often achieved wide powers through its monopoly over the cemetery, a major source of secured income. In Central and South America the ḥevrah kaddisha gomelei ḥasadim for many years also controlled most other communal activities. In the United States it lost its power as two of its functions were commercialized; funeral parlors passed to private ownership and cemeteries to *Landsmanschaften and congregations.

Decline of Autonomy

The era of civic emancipation ushered in a gradual dissolution of the self-governing community. The evolution of centralized monarchies, the crumbling of the medieval social structure, the harnessing of Jewish leadership in the service of the state, Enlightenment as an inner solvent, early capitalism with its emphasis on individualism, loss of status of the rabbinical courts, financial bankruptcy – these were some of the powerful internal and external factors that spelled the doom of Jewish autonomy. Many declared that emancipation and autonomy were inherently contradictory; that once the individual Jew is granted equal civic rights he can no longer claim group privileges.

Between the two world wars, efforts were made in Eastern European countries to grant Jews, along with other nationalities, certain *minority rights. In Russia, Alexander Kerensky's short-lived provisional government of 1917 stirred Jewish hopes for national self-determination. Upon seizing power the Soviets too proclaimed the rights to autonomy of territorial nationalities. For a while autonomous regions and soviets enjoyed linguistic, judicial, and educational self-rule. *Birobidzhan was proclaimed such a region. However, atheistic and assimilationist trends as well as the incipient anti-Jewishness gradually eradicated Jewish communal life. The claim for minority rights was based on the ideology of Diaspora nationalism, or *Autonomism, which demanded from the state group rights along with individual equality. The experiment did not last long. Intense nationalism among the ruling states and the force of economic rivalry between the Jews and the local populations tended to shatter all good intentions. In Ereẓ Israel the central and local self-government granted by Turkey and by the Mandatory power offered the Jewish community wide autonomy, which was used constructively to help prepare for eventual independence. Only one community, the Keneset Israel, was recognized, the exception being the separate Orthodox community network (see *Agudat Israel).

The Voluntary Post-Emancipation Community

Hardly any trace is left in the post-World War ii period of either state-enforced group autonomy or of the minority rights program. Emancipated Jewry developed wholly voluntary associations and communal organs. These serve a wide variety of purposes, mainly religious and social organizations abound for cultural, recreational, and social services. There have also arisen societies for the defense of Jewish rights and for developing institutions that serve both the Jewish and non-Jewish residents of the state on a non-sectarian basis, such as hospitals, recreational centers, and universities, as well as employment and vocational agencies. The *Board of Deputies of British Jews, the *American Jewish Committee, the *American Jewish Congress, and many other national bodies specialize in defense or in broader community services. The Orthodox, Conservative, and Reform religious groups in Western Europe and the United States each have their own network of local congregations and of regional and national institutions.

See also sections on Minority Rights in articles on various European countries.

bibliography:

Baron, Community (1942), includes bibliography; Finkelstein, Middle Ages; Baer, Spain, 1–2; M. Wischnitzer, History of Jewish Crafts and Guilds (1965); I. Levitats, Jewish Community in Russia, 1772–1844 (1943); M. Burstein, Self-Government of the Jews in Palestine since 1900 (1934); J. Katz, Tradition and Crisis (1961), 79–134, 157–67.

[Isaac Levitats]

Autonomy

BIBLIOGRAPHY

Since the Enlightenment, the concept of autonomy has implied the capacity for self-regulation, and as a corollary of this capacity, the right to self-determination. Although many early thinkers from both the East and the West espoused the idea of self-regulation in some form, including Tertullian (second and third centuries), Thomas Aquinas (thirteenth century) and the Chinese philosopher Lao-tzu (sixth century bce), it is generally associated with the development of Kantian philosophy and with the liberalism of the English philosophers John Stuart Mill (1806-1873) and John Locke (1632-1704), as well as the Scottish economist Adam Smith (1723-1790).

The most significant figure in the development of autonomy as a grounding concept of moral philosophy is undoubtedly Immanuel Kant (1724-1804), whose critical philosophy rests on the presumption that all human beings are rational beings and that reason is defined by the capacity for self-regulation. Reason, in Kant’s analysis, is a faculty that permits individuals to subject themselves to law, not merely because it is their desire to do so, but because moral law, as the product of reason rather than empirical deduction, has a quality of necessity that is independent of any question of ends and, hence, of the desires felt by individual subjects. A crucial aspect of Kant’s moral philosophy, one that was later developed by Karl Marx (1818-1883), was the notion that reason and desire could be opposed to one another, and indeed, that the autonomy of moral law implies the independence of reason from desire.

Like Jean-Jacques Rousseau (1712-1778), who influenced him greatly, Kant felt that the implications of moral autonomy extended to the political realm: The development of individual capacities for self-regulation required freedom from restraint by those forces that might otherwise cultivate desire against reason. Accordingly, he is often interpreted as an advocate of limited government—though his conception of what constituted limited government should not be confused with that of the political liberals following Mill and Locke, or the Smithian economists.

Mill in particular shared with Kant a sense that the opposite of moral autonomy is “servile dependence.” Significantly, then, it was not society per se so much as the hierarchy of obligation and indebtedness that threatened the autonomy of the individual and his or her capacity to make free judgments. In the political realm, Mill’s theory implied that individuals exercise their freedoms in relation to other individuals, and it is this cooperation that provides the means by which consensual governments are constituted.

It fell to Adam Smith to explicate the processes by which individual freedom and the complex organization of society could be accommodated and sustained independently of any legislative authority. He theorized a natural tendency to “truck, barter, and exchange” as the ground of those processes by which the division of labor develops naturally. In the forms of economic liberalism that owe their debt to Smith, the idea of autonomy was thus closely linked to one of spontaneous self-order. And it was used to legitimate arguments against governmental intervention in markets and other forms of economic life.

Kant was never fully able to extend the formalism of his own argument to all persons (he withheld the faculty of reason from Africans and aboriginals, and he doubted the capacities of women or servants to exercise free judgment). Moreover, the formalism that was intrinsic to his argument also encouraged a conflation between the presumption of a universal faculty (reason) and the universal equality of all to exercise this faculty of judgment in the actual social sphere. Smith’s argument, like that of the liberal political economists who followed him, presumed that government exercises a more coercive and inhibiting influence on individuals than do other social forces, such as capital or organized labor. This presumption—that only states (through their legislative bodies) interfere with individual autonomy—has been one of the major objects of critique within radical political philosophy, from Marx forward. The crux of such critique has been a recognition of the complex social determinants of the very consciousness within which reason appears as a faculty, and a value as such. Even within liberal traditions, there is disagreement as to whether individual autonomy is better served by a government that regulates capital and other social institutions, or by one that allows corporations (including not only economic but also religious institutions) to be considered as individuals, and hence as entities whose regulation would constitute a violation of their rights.

Politically, the concept of autonomy no longer applies exclusively to the relationship between individuals and social institutions; it also describes the status of recognized minority communities within larger social contexts, and particularly state formations. In this case, autonomy is closely linked to the idea of a collective right to self-determination, and as such is provided for by the United Nations under the terms of the International Covenant on Economic, Social and Cultural Rights (adopted in 1966 and entered into force in 1976). This covenant not only provides for a right to self-determination, but also recognizes the right of “all peoples to freely dispose of their natural wealth and resources.” However, just as liberal theory is conflicted in its assertion of the rights of individuals while it insists that these rights cease to exist when they intrude upon the rights of another individual, the rights of “peoples” may conflict with the perceived prerogatives of states. This is especially likely when such states comprise several distinct ethnolinguistic communities, and when one or another community dominates numerically, economically, or historically through the exercise of force. The structure by which states “grant” autonomy to regions within their territorial jurisdiction expresses the ambivalence of this concept of autonomy.

BIBLIOGRAPHY

Kant, Emmanuel. 1998. Critique of Pure Reason. Trans. and ed. Paul Guyer and Allen W. Wood. Cambridge, U.K.: Cambridge University Press.

Mill, John Stuart. 2002. The Basic Writings of John Stuart Mill. Ed. J. B. Schneewing, with notes by Dale E. Miller. New York: Modern Library.

Rousseau, Jean-Jacques. 1994. Discourse on Political Economy; and The Social Contract. Trans. Christopher Betts. Oxford, U.K., and New York: Oxford University Press.

Schneewind, J. B. 1992. Autonomy, Obligation, and Virtue: An Overview of Kant’s Moral Philosophy. In The Cambridge Companion to Kant, ed. Paul Guyer, 309-341. Cambridge, U.K.: Cambridge University Press.

Smith, Adam. 1976. An Inquiry into the Nature and Causes of the Wealth of Nations. Ed. W. B. Todd. Oxford: Clarendon Press.

United Nations. 1966. International Covenant on Economic, Social, and Cultural Rights. http://www.unhchr.ch/html/menu3/b/a_cescr.htm.

Rosalind C. Morris

AUTONOMY

Autonomy (from the Greek autos for self and nomos for rule, governance, or law) is defined as self-determination or self-rule. Its original use in ancient Greece referred to the sovereignty of states, but Immanuel Kant (1724–1804) and others in the modern period applied the term to individuals. For Kant, one is autonomous when one subjects oneself to moral rules recognized by the rational self. In contrast, one whose decisions and actions are shaped by others without critical reflection on the individual's part is heteronomous. Autonomy brings with it moral responsibility, and the autonomous person is open to charges of negligence or recklessness in the uses of science or technology if proper precautions against risk are not taken. Autonomy may also refer to the self-governing nature of professions or groups, such as the scientific community. Furthermore technology that operates without regular instruction from a person is sometimes called autonomous technology.

Conditions of Autonomy

Autonomy has many faces. Joel Feinberg (1989) points out at least four meanings: the capacity to rule oneself; the condition of ruling oneself; the virtuous ideal of ruling oneself; and the authority to rule oneself. Gerald Dworkin (1988) highlights eight common uses. One commonality is the idea that autonomy, like freedom, combines two aspects: the negative condition of freedom from external constraints and the positive condition of a self-determined will. Those barred from acting in accordance with their will, for instance, by physical constraints or coercive threats, are not able to act autonomously despite what they may internally will. Their will is either rendered impotent by force or limited to such an extent that a reasonable person could be said to have no choice. Someone who offers a wallet in response to a threat with a gun (Your money or your life) can be said to will such an action, but not autonomously, given the lack of reasonable alternatives. Yet a person may fail to act autonomously even without the existence of external constraints.

Harry Frankfurt (1989) famously argued that one cannot be said to choose freely unless one's first order desires (what one wants) are themselves chosen or affirmed by one's second order volition. That is, to be autonomous, one must want to want what one wants. Reluctant addicts who desire more heroin may wish that they did not want it, but nonetheless succumb to the strong first order desire for the drug. According to Frankfurt, they do not act autonomously, though they are free from external constraints. In contrast, rational agents who carefully reflect on their first order desires, identify with their preferred desires, and then act accordingly, are autonomous due to this vertical alignment of desires.

One problem with this view is that a person could have this vertical alignment of desires only as a result of undue interference from a third party (e.g., a hypnotist), making the identification inauthentic. This problem led Dworkin (1986) to add a procedural independence criterion to the concept of autonomy, meaning that to be autonomous one must identify with one's desires for reasons that are one's own. Yet some reasons that appear to be one's own may in fact be part of a larger system of values that has shaped the very person one becomes, and the desires one forms. For instance, a scientist's first order desire may be to receive a grant. The scientist may critically reflect on this desire, and approve of it, recognizing that grants are the way to succeed in science (they support work that leads to progress, publication, and future grants). So it appears that the scientist acts autonomously in applying for the grant. But the kinds of grants that a scientist may submit (or that have any likelihood of being funded), are in large part dependent on broader forces: governmental agendas, money-making prospects, and what counts as a hot issue. Has the scientist autonomously chosen the specific focus of the research? Traditional theories of autonomy do not allow much room for critique of background conditions that may unjustly or unduly shape an individual's desires and identification with those desires.

Relational Autonomy

The difficult question of determining when, if ever, anyone is truly free of external constraints that inhibit autonomy has led some feminist theorists to offer a theory of relational autonomy. Relational autonomy is built on the idea that our selves are relational and social, rather than essential and ontologically independent. Marilyn Friedman (1999) proposes an autonomy model that requires integration of first and second order desires, without putting priority on second order desires (sometimes a first order desire may be more authentic than what one has been socially shaped to believe one ought to want, especially under conditions of discrimination).

In a complementary manner, Diana Meyers (1999) argues that autonomy requires certain competency skills (e.g., self-definition, self-discovery, self-direction) that allow for sufficient critical reflection on one's desires and choices. If a social context impedes the development of competency skills for certain groups (e.g., women or racial minorities), then such people may never achieve full autonomy.

However Meyers (1999) allows for degrees and spheres of competency, which can result in partial autonomy. In the case of the scientist, investigation of the fairness of background conditions that determine the focus and availability of grants would be part of determining the individual's degree of autonomy (and resultant responsibility for actions). Contemporary life takes place against a large technological system (roads, electrical utilities, water systems, phone service, and others) that inevitably shapes the kinds of choices individuals can make. Relational autonomy theorists insist that the fairness of such background conditions be evaluated as part of our understanding of individual autonomy.

Significance of Autonomy for Moral Practice

Our theoretical understanding of individual autonomy will have significant effects on the use and meaning of autonomy in practical settings in medicine, law, scientific research, education,and more. In medical ethics, for instance, respect for autonomy is often considered the most important moral principle (Beauchamp and Childress 2001). It protects patients from paternalism, respects differences in individual values, and allows patients to refuse unwanted treatment. The principle of respect for autonomy includes rules regarding truth telling, promise keeping, and informed consent. Informed consent, in turn, consists of requirements of patient competency, disclosure of information, patient comprehension, voluntariness, and ongoing consent. Yet such conditions are often not guaranteed by simple informed consent documents, and even when fulfilled, they may "mask the normalizing powers of medicine" (Sherwin 1998, p. 28) that set the standards for competency, relevant information, and voluntariness.

Background conditions may also influence the degree to which one is autonomous in regard to new technologies. Available technologies can increase an individual's autonomy, for instance, when an insulin pump allows a diabetic person to avoid the constraints of dialysis, or a computer message board allows a patient with Lou Gehrig's disease to communicate preferences. Such technologies increase options, enhancing autonomy.

However some medical technologies, offered for the betterment of the individual, may in fact decrease autonomy, in that they override individuals' unpopular preferences. Some deaf individuals reject cochlear implant technology, some amputees refuse prosthetic replacements, and some intersexual people argue against sex-definition surgery. The available technologies, they warn, appear to increase options when in fact they eliminate other, less popular options, forcing individuals to fit the norm.

In the traditional models of autonomy, individual choice takes priority. But with relational autonomy, individual choices are only as valuable as their historical and relational precursors. Thus rather than taking a treatment request at face value, a relational autonomy model recommends the following:

1. lively dialogue, including critical questions regarding competency skills and the context of desire formation (our self-knowledge is in part social, and so engagement in dialogue should be seen as helpful rather than as a sign of disrespect) (McLeod 2002);
2. more respect for people who are only partially autonomous (e.g., children, individuals with mental retardation, mental illness, or senility);
3. recognition that patients may autonomously make decisions based on their familial situations (e.g., requesting assisted suicide because they do not want to be burdens on their families).

Indeed, on the relational autonomy model, making a choice without reference to our social context appears inauthentic rather than autonomous (Wolf 1996). Perhaps the most contentious issue of autonomy is determining when one's context undermines rather than engenders one's capacity for self-determination.

Autonomy in Science and Engineering

Professions or groups, as well as individuals, may be autonomous to the extent that they are self-governing. The autonomy of the scientific community has been defended as important for the preservation of free inquiry that results in knowledge production. Preserving that autonomy requires defining the boundaries and norms of the community. Free inquiry, for instance, may be stifled when academic scientists partner with private industry in order to gain grants that support the university as well as their own research. Such partnerships may decrease scientific autonomy by limiting the focus of investigation to what is marketable and/or profitable, and discouraging the sharing of results and methods in order to protect patents and preserve trade secrets. Scientific investigation will always be tied to funding, but must be protected from influences that threaten to corrupt the scientific process.

Yet with autonomy comes responsibility. Scientists who freely choose to develop nuclear weapons, or who experiment on genetically modified foods, retain some responsibility for the societal risks incurred in their work. The idea that science is value-free and that the responsibility for using or misusing scientific data rests with society at large rather than with the scientists who undertake the research is difficult to defend. Value-laden decisions are made throughout the scientific process. Scientists who retain autonomy in their profession must also accept the responsibility to avoid recklessness and negligence in respect to the risks created by their research (Douglas 2003).

Furthermore the value of free inquiry is limited when it threatens to undermine even more fundamental issues, such as access to free inquiry itself (Kitcher 2001). In defending this claim, Kitcher considers the work of sociobiologists and evolutionary psychologists who have attempted to support inegalitarian racial views that themselves threaten the ability of racial minorities to participate in scientific debates. Scientific autonomy, then, may also be limited by background conditions. A move to more democratic regulation of science (involving lay citizens) has been suggested as a possible remedy for these problems, highlighting again the relation between scientists and the broader community (Kleinman 2000).

Professional autonomy among engineers diverges from that of scientists in that engineers tend to have less individual autonomy on the job and more direct public impact in their work. Most engineers, at least in the United States, are employees rather than independent contractors, resulting in less opportunity for self-determination on the job, and setting up potential conflicts between their obligations as employees and their duties to exercise professional judgment. An employer that demands a sacrifice in safety precautions in the interest of profit or timeliness, for instance, may interfere with the autonomy of the engineer (Mitcham and Duvall 2000). Because engineering work often results in public technologies or structures (bridges, transportation, and others), failures of professional judgment can have widespread impact, as in the famous cases of the Challenger disaster, the American Airlines DC-10 crash of 1979, and the Hyatt Regency hotel walkway collapse (Whitbeck 1998). Whistleblowers may be required to sacrifice corporate loyalty (and job security) in the name of protecting the public good.

SARA GOERING

SEE ALSO Autonomous Technology;Human Subjects Research;Informed Consent;Kant, Immanuel;Medical Ethics

BIBLIOGRAPHY

Beauchamp, Tom, and James Childress. (2001). Principles of Biomedical Ethics, 5th edition. New York: Oxford University Press. Classic text in medical ethics.

Douglas, Heather. (2003). "The Moral Responsibilities of Scientists: Tensions Between Autonomy and Responsibility." American Philosophical Quarterly 40(1): 59–68.

Dworkin, Gerald. (1988). The Theory and Practice of Autonomy. New York: Cambridge University Press. Excellent discussion of the concept of autonomy and its significance.

Dworkin, Gerald. (1989). "The Concept of Autonomy." In The Inner Citadel: Essays on Individual Autonomy, ed. John Christman. New York: Oxford University Press.

Feinberg, Joel. (1989). "Autonomy." In The Inner Citadel: Essays on Individual Autonomy, ed. John Christman. New York: Oxford University Press.

Frankfurt, Harry. (1989). "Freedom of the Will and the Concept of a Person." In The Inner Citadel: Essays on Individual Autonomy, ed. John Christman. New York: Oxford University Press.

Friedman, Marilyn. (1999). "Autonomy, Social Disruption, and Women." In Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self, eds. Catriona MacKenzie and Natalie Stoljar. New York: Oxford University Press. The book contains a great collection of works on relational autonomy.

Kleinman, Daniel Lee. (2000). "Democratization of Science and Technology." In Science, Technology and Democracy, ed. Daniel Lee Kleinman. Albany: State University of New York Press.

McLeod, Carolyn. (2002). Self Trust and Reproductive Autonomy. Cambridge: MIT Press.

Meyers, Diana. (1999). "Intersectional Identity and the Authentic Self: Opposites Attract!" In Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self, eds. Catriona MacKenzie and Natalie Stoljar. New York: Oxford University Press.

Mitcham, Carl, and R. Shannon Duvall. (2000). Engineering Ethics. Upper Saddle River, NJ: Prentice-Hall.

Sherwin, Susan. (1998). "A Relational Approach to Autonomy in Health Care." In The Politics of Women's Health, ed. Susan Sherwin. Philadelphia: Temple University Press.

Whitbeck, Carolyn. (1998). Ethics in Engineering Practices and Research. Cambridge: Cambridge University Press. Excellent introduction to ethical issues in engineering.

Wolf, Susan. (1996). "Gender, Feminism, and Death: Physician-Assisted Suicide and Euthanasia." In Feminism & Bioethics: Beyond Reproduction, ed. Susan Wolf. New York: Oxford University Press.

AUTONOMY

Autonomy expresses the idea that persons should direct their own actions and be free from coercion or undue influences by others on their actions and deliberations. The concept of autonomy has touched all areas of social life and has had a pronounced effect on medical ethics and medical practice. Patient autonomy emerged in the 1960s and 1970s in the great social movement that created a diverse range of civil rights, some constitutionally protected, including expanded individual rights in health care, such as access to abortion, end-of-life decision making, and privacy. The clearest expression of autonomy in medicine is the doctrine of informed consent.

Informed consent defines a set of patient rights and reciprocal obligations for health professionals. Informed consent means that patients have a right to make autonomous choices about their medical care. To do so, they must be given information about their medical condition, treatment alternatives, and the burdens and benefits associated with the recommended treatment and its alternatives. Since this information is largely in the hands of physicians, the doctrine of informed consent creates the obligation that physicians disclose information to patients and allow patients to make their own medical decisions. An implication of informed consent is that patients can refuse treatment.

The right to refuse treatment, including life-saving or life-sustaining treatments, has come to be firmly established in law. Recognizing that patients sometimes lack the ability to make their own medical decisions, legislatures created advance directives. Advance directives empower patients to direct their future medical care even when they have lost the ability to make their own medical decisions. These ideas have radically transformed late twentieth-century medicine. In a similar vein, the concept of autonomy has affected our understanding of aging and being old as well.

On the positive side, autonomy has supported criticisms of ageism and other social attitudes and practices that limited the freedom of elders or that relegated elders to a secondary social status. Autonomy has also supported the elimination or modification of age-based discrimination, such as a mandatory retirement age or the proscription of the use of age in employment decisions. Autonomy is also at work in the idea that elders in retirement should remain active and engaged. Their social function is to enjoy an earned leisure and to maintain independence from the responsibilities characteristic of their preretirement lives. The principle of autonomy has thus introduced into gerontology a focus on the individual who is regarded independent of other individuals or social structures like the family. It has highlighted a certain understanding of the autonomous individual as one who has the capacities for self-directed and independent action, deliberation, and decision-making, and it has made these values preeminent. These assumptions demarcate a standard view of autonomy that has important implications for aging.

Key features

Four features of this view of autonomy are particularly significant for aging. First, the autonomous person is regarded outside a developmental framework and is assumed to fully possess all autonomy-related faculties. Thus, the standard view of autonomy has no ready way to accommodate incapacity. Second, autonomy implies independence and self-direction. States of dependence are regarded as problematic for true autonomy. Third, autonomy focuses on the individual in abstraction from social structures like the family, so the aged individual is seen as possessing value, purpose, and rights separate from the social and personal relationships that provide everyday support and assistance. Fourth, the standard view of autonomy incorporates a simplifying assumption that freedom of choice or decision-making expresses the most important dimension of being autonomous. Each of these features of autonomy creates a range of problems in the context of aging.

Standard treatments of autonomy focus on individual action and choice without regard for the medical, psychological, or social context of the individual whose autonomy is at issue. This creates special problems for thinking about those processes of aging that create dependencies or compromise the capacities of the elder. In these situations, autonomy and its corollary of rights cannot fundamentally aid elders whose struggle is not against oppression, but to maintain a personal sense of worth and dignity in the face of loss. In stressing the robust exercise of freedom, autonomy can distort the complex phenomenology of aging by vastly oversimplifying what being autonomous involves as one grows old.

Actual expressions of autonomy throughout the life span are always subject to a wide range of circumstances and conditions. For example, metabolic states can induce confusion and alter one's ability to think clearly or to carry out intended choices. Psychological states can distort one's ability to perceive reality accurately and can affect decision-making. Social factors also influence the ways in which one experiences the world and the choices that one practically envisions.

A society that prizes an idealized view of individual action and choice and that values independence, self-direction, and self-control understandably tends to disvalue conditions that compromise action or involve decisional impairments or states of dependence. The paradox of autonomy in aging is that the ideal of autonomy expressed in the robust independent decision maker is incongruent with some of the realities of loss that are associated with growing old. This raises the question: How can the ideals of autonomy be reconciled with the realities of aging?

Implications for aging

Frail elders who have experienced medically related incapacity often receive medical care in home with assistance from family members, neighbors, or friends. They sometimes rely on others for assistance in securing health care, filling prescriptions, or in complying with recommended medical regimens. Respecting the actual autonomy of such an elder entails more than respecting the right of informed consent or confidentiality. Respecting the actual autonomy of the elder requires that health professionals carefully examine the ways that the standard delivery of health care services can compromise an already impaired autonomy. For example, if elders require assistance in receiving health care services because they have hearing or visual impairments, assistive hearing devices or large-type patient information material or prescription medicine instructions can minimize or eliminate the direct reliance of some elders on others for the most basic elements of medical care.

Emphasizing informed consent can be problematic whenever elders are inclined to defer to authority figures. Such elders are more inclined to accept physician advice than are people in their middle years. For these elders, the right to informed consent is less meaningful than is the opportunity to receive authoritative advice from a physician. Because these elders would prefer to be told what to do rather than being provided with an array of choices, the challenge for physicians involves identifying the basic values or beliefs of patients and incorporating them into a treatment plan.

When physical infirmity associated with aging reduces a person's ability to act independently, it may not alter the person's decisional capacity. Focusing on independence of action may obscure the fact that actual expressions of autonomy always involve two distinct elements, a decisional and an executional element. A person may be autonomous in the sense of being able to make his or her own decisions, but may not be able to carry them out. Hence, autonomy is not lost when a person is unable to carry out a decision because of frailty or physical infirmity. To respect such a person's autonomy requires more than simply allowing them to make choices. It creates the obligation to assist them in carrying out their choices. Thus, respecting actual autonomy in the domain of choice entails that we assist elders in realizing their choices. This can be a formidable challenge in some instances, but in other circumstances minor accommodations are all that is needed.

Assistive devices ranging from hearing aids or wheelchairs to direct assistance in carrying out activities of daily living can serve to sustain the reality of autonomy in a frail elder. Autonomous choice in abstraction from the existential setting of choice is meaningless if the conditions required for its execution cannot be fulfilled. Autonomy that is impaired somewhat by executional inabilities can become a significant problem if the material means for providing executional assistance are not available. For this reason, poverty directly impairs one's autonomy, yet is a condition that is seldom regarded as infringing freedom. Although limitations in executional abilities occur throughout life, they are more significant as one ages and suffers the disabilities associated with growing old. Analogously, decisional impairments associated with dementia or Alzheimer's disease does not obliterate autonomy, but does create challenges for how autonomy of such persons is to be respected.

Because a person can no longer make autonomous choices, it does not mean that their autonomy cannot be respected. All autonomous choices are based on the person's preferences or values that are developed, often over a lifetime. The beliefs and values that guide a person's life is thus the key to respecting their autonomy whenever one's decisional capacity is impaired. In the absence of formal advance directives, these beliefs and values can provide a basis for respecting an elder's autonomy. To do so, however, one needs to know who the elder is. This requirement creates resource demands on caregivers and on a system of care that focuses on respecting patients' choices without regard for the background values or reasons that guide the choice.

Loss of independence is often regarded as the most serious impairment of autonomy. This view creates unrealistic expectations in the context of growing old. In America, ownership or occupancy of one's own home is a cultural value epitomized in the phrase that one's home is one's castle. It is no wonder, then, that living independently at home has become the last stand for elders struggling to maintain their self-respect and sense of dignity. Unfortunately, the requirements for assistance in daily living can become so great that elders cannot provide for themselves in the home. Hence, a struggle ensues between protecting the welfare of the elder and maintaining the elder's sense of identity and independence. Ironically, this struggle exists because we have not taken the demands of autonomy seriously enough.

Social considerations

As a society, we have ignored the material and social conditions that are required for autonomy to flourish. We have allowed autonomythwarting institutions to dominate the care of the infirm and sick old. Rather than building autonomy-sustaining institutions, long-term care of elders has accepted a medical paradigm of the delivery of services rather than a paradigm of providing an environment suitable for sustaining a compromised autonomy.

The nursing home in America has become the icon of the loss of independence. The nursing home often is a setting in which the individual is subject to impersonal institutional rules rather than self-control. Even when elders do not require skilled care, the medical model that dominates nursing homes creates a hierarchical and professionally dominated setting that forces residents to live under significant restrictions. In this context, it is understandable that reformers have used the concept of autonomy as a watchword for reform, but reforms that feature increased choices or rights cannot address the personal loss of dignity that elders experience.

Autonomy has traditionally supported liberation. In the nursing home, a patient rights' movement has developed that insists that residents of nursing homes be accorded basic rights, including degrees of self-governance and, most importantly, preservation of the rights that they possessed outside the nursing home. Liberating elders from an oppressive system, however, is not feasible if the elders truly need the supportive services that the nursing home provides.

While autonomy is an important value, respect for autonomy is a remarkably abstract formula for expressing the complex range of ethical obligations associated with respecting elderly persons. Persons deserve respect not only because they are capable of self-determination, but also because they are persons. In actuality, persons exhibit varying degrees and kinds of autonomy. Unfortunately, emphasizing the ideals of independence and unfettered decision-making that dominates most treatments of autonomy cannot be developmentally sustained throughout the life span. In contrast, respect for actual autonomy means that society must address the concrete actuality of the persons in question.

To respect autonomy thus requires that we develop policies and procedures that move beyond a focus on individual choice or decision-making to take into account developed personality and the limitations that actually define people as they age. The challenge of autonomy in aging is the challenge of respecting elders' actual expressions of autonomy in the face of compromised capacities without losing the protections afforded by the rights associated with traditional readings of the principle of autonomy.

George J. Agich

See also Advance Directives for Health Care; Age Discrimination; Life Span Theory of Control; Refusing and Withdrawing Medical Attention.

BIBLIOGRAPHY

Agich, G. J. Autonomy in Long-Term Care. New York: Oxford University Press, 1990.

Gamroth, L. M.; Semradek, J.; and Tornquist, E. M., eds. Enhancing Autonomy in Long Term Care: Concepts and Strategies. New York: Springer Publishing Company, 1995.

McCullough, L. B., and Wilson, N. L., eds. Long-Term Care Decisions: Ethical and Conceptual Dimensions. Baltimore and London: John Hopkins University Press, 1995.

Moody, H. R. Aging: Concepts and Controversies. Baltimore and London: John Hopkins University Press, 1998.

Schneewind, J. B. The Invention of Autonomy: A History of Modern Moral Philosophy. Cambridge: Cambridge University Press, 1997.