The concept of autonomy and its role in Kantian ethics.

Among bioethicists, and perhaps ethicists generally, the idea that we are obliged to respect autonomy is something of a shibboleth. Appeals to autonomy are commonly put to work to support legal and moral claims about the importance of consent, but they also feed a wider discourse in which the patient’s desires are granted a very high importance and medical paternalism is regarded as almost self-evidently indefensible. Beauchamp and Childress’s four principles—which have, for better or worse, shaped a large portion of modern bioethical debate—do not officially grant respect for autonomy any precedence over beneficence, nonmaleficence, or justice. Nevertheless, there is no shortage of people who accept ‘‘principlism’’ and who have taken the principle of respect for autonomy to be ‘‘first among equals.’’ Others reject principlism but still hold respect for autonomy to be important—perhaps overridingly so. But what does ‘‘autonomy’’ mean? If we are prepared to say that autonomy is important, or more or less important than something else, it is not crazy to think that we ought to be clear concerning that about which we are speaking. The meaning of the word autonomy is not obvious: the list of competing interpretations at the start of Dworkin’s Theory and Practice gives a flavor of its polysemy. Maybe the meaning of any given word is protean and context dependent, but it would remain possible even then to show that a particular interpretation is incoherent, or that the word is being misappropriated. I cannot give a comprehensive survey and analysis of the meanings of autonomy here. But because the modern interest in respect for autonomy can be traced to Kant, it is worth examining what he holds the nature and characteristics of autonomy to be. The warrant for such an examination is strengthened by the fact that at least some bioethicists think not only that autonomy is important and that respect for it makes certain demands, but also that it is best understood in ostensibly Kantian terms. Yet Richard Dean has argued that autonomy in the mouth of a bioethicist has little, if anything, to do with Kant’s use of the term, and although my concerns differ from Dean’s, I agree that the bioethicist’s autonomy is different from Kant’s, and I shall suggest that one of the prevailing uses of Kantian autonomy within bioethics— that we ought to respect it as a way of respecting persons—is mistaken. A Kantian bioethic is not what many bioethicists think it is.