Monday, May 01, 2006

Asymmetric Autonomy

"You can have any colour you want, as long as it's black." - Henry Ford.

I've recently come across two very different medical policies with one thing in common: they grant patients an oddly asymmetric autonomy, guaranteeing them only the right to cause more death. If patients instead make the choice which favours life, their doctors are free to override it. Really. I don't know what the world's coming to.

1) via Right Reason (N.B. I'm unsure of the partisan source's reliability):
According to Smith, the bioethics committee at St. Luke's is applying an emerging approach to treatment decisions called "futile-care theory." He summarizes:

"In order to honor personal autonomy, if a patient refuses life-sustaining treatment, that wish is sacrosanct. But if a patient signed an advance medical directive instructing care to continue -- indeed, even if the patient can communicate that he or she wants life-sustaining treatment -- it can be withheld anyway if the doctors and/or the ethics committee believes that the quality of the patient's life renders it not worth living."

Assuming the story is accurate: The only possible justification I can think of for this would be if it was an issue of limited resources for publicly-funded healthcare, resources that could be better spent helping others in need. (Though presumably a better option would be to boost health funding enough that all those in dire need can be adequately cared for.) But that would have nothing to do with judgments of whether or not the patient's life was "worth living". The question would rather be whether the limited health resources could do more good elsewhere. (The answer might be "yes" even if this dying patient has a life still worth living.) In any case, it's incredible that external authorities could override an individual's own judgment of whether their life is worth living. Unbelievable. (They clearly need to be taught a thing or two about subjectivist theories of welfare!)

2) via No Right Turn: doctors are duty-bound to respect the wishes only of those who don't wish to be organ donors. It seems that doctors are perfectly entitled to let perfectly good organs go to waste, against the express wishes of the deceased, if for any reason they do not wish to harvest them. (It's hard to think why they'd want to cause needless waste here, but it's the asymmetry of principle that I find striking. For the more practically minded: apparently one common reason is "respect" for the religious beliefs of grieving relatives. Never mind the person whose life those organs could have saved!)
And I find it kind of funny
I find it kind of sad
The dreams in which I'm dying
Are the best I've ever had
I find it hard to tell you
'Cos I find it hard to take
When people run in circles
It's a very, very...



  1. Of course the principle of autonomy is asymmetric. It's a principle of non-interference, based on the ideal of negative liberty, and dependent on the do/allow (or action/inaction) distinction. It's not clear if the asymmetry in these two examples goes beyond that inherent asymmetry. Autonomy gives you the right to prevent other people from doing things with your body, either by giving you unwanted medical treatment while you're alive or (at least according to some views) by taking your organs after you're dead and putting them to use in other bodies. It does not give you the right to demand dialysis or to force doctors to take your organs and surgically implant them in someone else.

    Autonomy could give you the right to make a contract with someone who promises to give you dialysis for as long as you need it (that would usually be "insurance") or who promises to put your organs to use if it is practicable and beneficial. It's not clear if these contracts were in place in the cases you bring up, but my suspicion is that they aren't. I think that organ donation, in its most common form, is just a matter of granting permission, and I'd guess that "futile care" practices don't involve a breach of contract.

    I don't take autonomy to be an inviolable, and I think that there are many relevant considerations besides autonomy at play in these kinds of situations, but I think that it does make sense for non-interference and the do/allow distinction to leave a sizeable footprint on these kinds of policies.

    I'm not sure what the futile care policy in question actually says, but there is something in the neighborhood of what Smith describes that I'd find reasonable. If a medical treatment would only prolong a person's life by a little bit, and the person's quality of life for the additional time would be low (because of pain or low functioning), and the treatment would be expensive, then it seems reasonable not to provide the treatment (at least in many cases) regardless of the wishes of the person and their family. That would be futile care. If all three of those conditions are reversed, and an inexpensive treatment would add a significant length of high-quality time to a person's life, then it seems appropriate to make every effort possible to give the treatment, perhaps only stopping short of an outright violation of the person's insistent demands for non-interference (combined with evidence that the person is competent to make these decisions). Things get more complicated in many of the intermediate cases, where these three considerations are not all at the same extreme, and there is some uncertainty about them. Like I said, I don't know how the Texas law navigates these issues, but it could at least be based on reasonable motivations.

  2. Hmm, good point. I guess the fact that both cases "favour death" is merely incidental to the real reason for asymmetry then. Which makes it all merely unfortunate, rather than unfathomable and depressing.

    I probably should've seen that. Oops.

  3. Richard,
    The limited resource in health care is generally not money it is people. So spending more money on it doesn’t help much. Besides that money always has to be diverted from somewhere else. It is only meaningful to talk about spending more money in terms of what you are going to do to get that extra money.

    I think it is a ridiculous situation if the medical authorities can be overruled by the individual in regard to the best allocation of their resources. Obviously many individuals would want all the resources allocated to them (and they might indeed live to be 1,000 at the cost of everyone else).

    > Apparently one common reason is "respect" for the religious beliefs of grieving relatives.

    I think you can technically override the dead person's wish to NOT donate also. BUT it is les likely because
    1) The theory that the dead cannot be harmed by what happens to their body but their relatives can
    2) The relatives are still alive to fight you - the dead person is not.


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