Medical care and the limits of autonomy

Talk to a natural childbirth or homebirth advocate for more than a few minutes and you are bound to be treated to a disquisition on autonomy. There is the standard assertion on the right to control your own body,the rejection of paternalism in medicine and the insistence that it is the responsibility of the physicians and nurses to do whatever patients tell them. Invoking autonomy, therefore, is seen as the trump card.

That, however, assumes that there is no limit to autonomy within a medical setting and that assumption is wrong. Consider a classic problem of medical ethics:

What if a patient requests amputation of a healthy leg?

Applying the straightforward claims about autonomy invoked by NCB and homebirth advocates would leave us with only one conclusion: as long as the patient is mentally competent, he or she has the right to expect that a request for healthy limb amputation must be honored. Is that what medical ethics and the principle of autonomy require? Many medical ethicists would argue against that view.

If the right of autonomy does not entitle patients to demand and receive amputation of a healthy limb, there must be some limits. What might those limits be?

To answer the question, it helps to understand what the right to autonomy really means.

In the introduction to Healthcare Decision-Making and the Law; Autonomy, Capacity and the Limits of Liberalism, Mary Donnelly notes:

Since the latter part of the twentieth century, the law's approach to healthcare decision· making has centred on ensuring respect for the principle of individual autonomy. In t his, the law reflects the predominant ethical status which has been accorded to the principle. Thus, John Stuart Mill's famous aphorism that '[o]ver himself, over his own body and mind, the individual is sovereign' might be seen as the defining summation of principle. This principle is given legal effect in Cardozo's often cited dictum that 'every human being of adult years and sound mind has a right to determine what shall be done with his own body.'

Or as Kellie Williamson explains in Healthy Limb Amputation, Bioethics and Patient Autonomy:

...Ultimately, autonomy is about an individual being able to live their own life according to their own idea of what a good life entails. In other words, it involves self-determination and self-rule, and is closely associated with personal identity. In order for each person to be autonomous, other people must respect that person's autonomy. Respect for autonomy can also be extended to the state, institutions and health-care professionals...

However, even a right as fundamental as autonomy has limits. In Autonomy, the Good Life, and Controversial Choices, Julian Savulescu notes:

According to the German philosopher, Immanuel Kant, our autonomy is tied to our rational nature...

There are compelling independent ethical arguments to suggest that the exercise of full autonomy requires some element of rationality ... These arguments are based on the concept of self-determination... not mere choice but an evaluative choice of which of the available courses of actions is better or best. The reason that information is important is to enable an understanding of the true nature of the actions in question and their consequences. But if information is important, so too is a degree of at least theoretical rationality to draw correct inferences from these facts and to fully appreciate the nature of the options on offer.

In other words, an autonomous decision is not merely a wish, but a decision made with appropriate information and rational consideration of the outcomes. Therefore, simply telling your doctor that you want him to amputate your healthy leg is not a sufficient reason for him to honor your request.

How do we determine whether a person is making a rational decision? Savulescu argues that it does not rest on whether the decision in prudent; imprudent decisions can still be honored. The issue is whether the imprudence is rational or irrational, which he defines as follows:

Rational imprudence is imprudence based on a proper and rational appreciation of all the relevant information and reasonable normative deliberation. Some other reason grounds the action beside prudence - this is typically the welfare of others. Thus we should respect decisions to donate organs or participate in risky research, if these are based on a proper appreciation of the facts. However, merely citing a normative reason is not sufficient to make some action, all things considered, rationally defensible . To donate one's healthy kidney to a sick relative would not be rationally defensible if the chances of rejection were very high. There must be a reasonable appreciation of the values in question.

The classic example of rational imprudence is the refusal of a Jehovah's Witness to accept a desperately needed blood transfusion. The decision may be imprudent because it can lead to death, but it is rational because the individual values spiritual well being above health and even life itself.

On the other hand:

Irrational imprudence is imprudence where there are no good overall reasons to engage in the imprudent behavior. The explanation might be that the person is not thinking clearly about information at band or holds mistaken values or wildly inaccurate estimates of risk. We should attempt to reason with and try to dissuade the irrationally imprudent.

Theoretically, then, it is permissible to amputate a healthy limb on request, but only when the person desiring the amputation has a complete appreciation of the results of this choice.

What does this mean for natural childbirth and homebirth advocates?

Autonomy does not mean that medical professionals are required to honor all requests. Medical professionals are not required to honor requests when the patient fails to understand the consequences and therefore is not making a rational choice, or understands the possible consequences but wildly underestimates the risk of those consequences occurring.

Indeed, these are the arguments that patients themselves often make in the wake of bad outcomes that derived from their own choices. Consider the case of attempted vaginal birth after Cesarean that leads to uterine rupture and death of the baby. Patients have argued successfully in courts of law that although they did make a rational decision to attempt labor after a previous C-section (and signed a consent form acknowledging that they had been apprised of the risks), they failed to understand that the baby could really die, or they failed to understand that even when there is only a small risk, catastrophic outcomes will occur.

This is why natural childbirth and homebirth advocacy are so problematic. Most professional natural childbirth and homebirth advocates have a poor understanding of the risks of their choices because they have been misinformed by other NCB and homebirth advocates, and because they lack the most basic understanding of childbirth, obstetrics and statistics, leaving them unable to evaluate their beliefs in any systematic way.

There are limits to the principle of autonomy. You can't expect a doctor to amputate a healthy limb just because you request it. Similarly, if you are an NCB or homebirth advocate, you can't expect obstetricians to violate standards of practice, just because you request it. That is not what the principle of autonomy demands.