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A review of Autonomy and Trust in Bioethics, by Onora O'Neill. Cambridge: Cambridge University Press, 2002. ISBN cloth: 0521815401; paper: 0521894530.

In this series of lectures, Onora O'Neill argues that while bioethicists continue to emphasize respect for individual autonomy, public trust in the areas of medicine, science, and biotechnology continues to erode. Why? She believes there is an inherent tension between the conception of individual autonomy used in bioethics and the concept of trust. In her view, a reliance on principled autonomy would be more adequate for the needs of bioethics and compatible with valuing trust.

According to O’Neill, autonomy, as it is used in bioethics, is primarily associated with independence or the ability to make independent decisions. Also, O'Neill argues that in practice this conception of individual autonomy is usually reduced to a demand for informed consent. "What is rather grandly called 'patient autonomy' often amounts simply to a right to choose or refuse treatments on offer, and the corresponding obligations of practitioners not to proceed without patients' consent" (37). While she agrees that informed consent is important, she believes that an emphasis on this conception of autonomy can work against restoring trust.

As the author points out, expressions of individual autonomy can be good or bad (3, 25). This means that increasing individual autonomy does not automatically increase trust. Individual autonomy (as it is currently conceived) emphasizes independence from others whereas trust requires developing relationships with others (24-25).

O'Neill proposes a conception of principled autonomy taken from Kant. She argues that Kant's conception of autonomy is not individual, but is instead a matter of acting on principles and obligations. The principle of autonomy requires that we only act on choices that could be made into universal laws or principles. Thus, principled autonomy is a matter of restraint. O'Neill notes:

Kant's concern is not a self that actually legislates for all, but principles that are fit to be laws for all. The stress he places on the term self-legislation is on the notion of legislation: the advocates of individual autonomy by contrast stress the notion of self and have little to say about any conception of (moral) legislation. (85-86, Author's emphasis)

She argues that adopting a conception of principled autonomy gives us a foundation of basic ethical requirements. Also, this conception is more compatible with trust because it forbids deception and coercion.¹

The foundation of basic ethical requirements seems to be O'Neill's main concern. As alluded to earlier, she believes that without other ethical constraints, individual autonomy is not an intrinsic good. Yet, I am not convinced that her version of principled autonomy is

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going to be as helpful as she claims.

First, O'Neill admits that the principles or laws derived using principled autonomy will still need to be interpreted in practice (95). As she puts it, principles underdetermine actions and, thus, must be complemented by exercising practical judgment (124). Even if principled autonomy obligates all health care practitioners to avoid deception and coercion, each individual practitioner must still use her moral judgment to decide what acts count as deception and coercion in any particular instance. How is this any different than what occurs in current practice? All health care practitioners are currently obligated to uphold ethical guidelines that prohibit deception and coercion and currently use their own judgment to interpret those guidelines.²

Second, the different conceptions of autonomy O'Neill introduces appear to apply to different groups or, at least, appear to develop from different contexts or debates. The conception of individual autonomy and requirements for informed consent developed in reaction to medical paternalism and a series of medical abuses. As O'Neill correctly points out, this is often referred to as "patient autonomy." The emphasis on independence and choice makes sense if we pay attention to the context in which this conception of autonomy developed. In contrast, O'Neill's discussion of principled autonomy focuses primarily on health care practitioners, insurance companies, and the media. According to O’Neill, principled autonomy turns our attention to obligations; therefore, it makes sense that her discussion shifts to those who are in power or those who are in charge of disseminating information. However, it is unclear how these two discussions related to each other. O'Neill claims, "A primary focus on interaction and relationships, on obligations and rights, does not prevent those committed to principled autonomy from assigning due - but no more than due - weight to individual autonomy" (O'Neill 96). Yet, it remains unclear from her discussion what patients would owe their health care providers based on principled autonomy (or how principled autonomy would apply to patients).

Despite these reservations, I agree with O'Neill that the dominance of the principle of autonomy (as it is currently conceived) is a problem for bioethics. I also agree that shifting our focus from a discussion of rights to a discussion of obligations (which she believes principled autonomy would do) could be a very productive move.

Much of our current emphasis on individual autonomy in bioethics was in reaction to paternalism. In that context, it made sense to emphasize individual rights or the right to choose. Even though I do not believe the problem of how to account for patient power in the health care system has been solved, I do agree there are many issues in bioethics that deserve more attention, for example; access to health care, the rising costs of health care, and potential problems with a health care system that seems bound to consumer demands. A discussion of these issues will likely need to shift to obligations (what we owe each other or what society owes certain groups) rather than a continued focus on individual choices.

In addition to her analysis of autonomy, O'Neill begins a philosophical analysis of trust. She points out that despite general mistrust of institutions, many individuals continue to trust specific practitioners. As O'Neill accurately points out, wholesale distrust is impossible; therefore, the question is with whom and how we should place trust (141-142). Her analysis of trust is quite thought provoking. I hope others will continue this discussion and analysis.

In addition, O'Neill discusses various cultural trends that have likely eroded trust such as the "audit agenda" and a sensationalized media. By the "audit agenda," O'Neill refers to a shift in institutional practices that replaces qualitative measures of performance with quantitative ones. Inevitably, the way these institutions work must also change to accommodate these new requirements. Although the quantitative measures are meant to ensure trust, they often increase distrust because they "formalize" trust, relay on external constraints, and obscure the workings of institutions (129-134). O'Neill also looks at how the media has undermined public trust. An emphasis on sensationalism over substance obscures what real issues are at stake and inhibits useful public discussion. She suggests some procedural standards for ethical reporting that would better reflect the original intents of a free press (Chapter 8).

Neither of these issues will be new to most bioethicists. Still, O'Neill is correct to highlight them. As she points out, trust can only be restored if people are able to (in some way) judge information and institutions for themselves. Thus, until we address these issues and others that obscure or unnecessarily complicate information, we will not be able to restore trust.

In conclusion, O'Neill's book will probably be of interest to a number of groups. Her general discussion of specific topics such as reproductive technologies, genetic privacy, and the media would be accessible to anyone interested in those topics. Most of her analysis of autonomy is also very accessible, but will probably be more meaningful to those working in philosophy or to academically trained bioethicists. She purposely uses footnotes sparingly so it is helpful if you have some familiarity with the literature she is discussing. This is especially true in her chapter on principled bioethics when she discusses some debates over Kant. However, I could also see this book being useful for an upper level undergraduate or graduate level bioethics course given the topics covered.

Sonya Charles, Michigan State University

Footnotes

¹ Her analysis of why principled autonomy forbids deception and coercion is similar to the classic account Kant gives against lying. In sum, it would be incoherent to deceive because if universalized it would undermine trust which is necessary for deception (98).

² For example, the American Nurses Association Code for Nurses includes "veracity (truth-telling)" as part of showing respect for patients, and the American Hospital Association's Patient Bill of Rights includes a right to obtain "complete current information concerning diagnosis, treatment, and prognosis" (quotes are taken from Ethics in Nursing, 3rd edition by Martin Benjamin and Joy Curtis. New York: Oxford University Press, 1992, 219, 221 respectively).