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A review of The Perversion of Autonomy: Coercion and Constraints in a Liberal Society, by Willard Gaylin and Bruce Jennings. Revised and Expanded Edition. Georgetown University Press, 2003.

ISBN: 0878409068; LC: 2002013910.

What is the meaning of freedom if we are fundamentally bound to each other? And what costs are we, as ostensibly free individuals, willing to incur by virtue of our membership in a society that seems to be torn between a slavish devotion to personal autonomy on the one hand, and the need for mutual cooperation and collaborative decision-making on the other?

In the first edition of The Perversion of Autonomy, Gaylin and Jennings, employing the tools of political theory, philosophy and psychology, have located the modern liberal society in precisely this struggle. The central question that the authors posed there was whether individual U.S. citizens and society are able to sensibly balance our devotion to freedom and autonomy with the welfare of the larger community. What they suggested is that, alas, we have sacrificed the latter for the former, and in doing so, have in fact begun to undermine the liberal and democratic society we seek to preserve.

In this second edition, Gaylin and Jennings offer us a more compelling and more passionate work. It is more passionate perhaps as a result of the immediacy that the events of September 11, 2001 have given to the autonomy vs. civic responsibility debate, both in the U.S. and globally. It is more compelling as a result of two new, provocative chapters on the crucial issues of forgoing life-sustaining treatment and physician-assisted suicide (PAS). These chapters, which the authors note were written at least in part as a response to the movements to legalize physician-assisted suicide and to defend euthanasia on moral grounds, advance the book's general argument by suggesting that even at the end of one's life -- and perhaps especially at the end of one's life -- autonomy fails as both an "overriding" value, as well as a substantive moral guide for our reasons, policies, and actions.

Indeed, the authors argue, it is rather significant that our debates surrounding individuals' rights to forgo life-sustaining treatment appear to have shielded us from the very multifaceted and human reality of what it might mean to live a good life and die a good death. In addressing the complex and profound questions of death and dying, they suggest, we find ourselves confronted not merely by the binary question of "Am I being coerced in my choices?" but by a whole host of concerns, including the importance of our "relational space" (250), or our personal, human, and communal relationships with each other. Without acknowledging these concerns, we are subsequently left contemplating a limiting and starkly "formulaic" notion of autonomous freedom of choice rather than allowing for the possibility of actual "self-sovereignty." In the end this deprives us of the opportunity to honor a life with a "dignified" (250) death, and to thus preserve the "integrity of the person in the extended social space surrounding the physical body" (244).

We make a similar mistake, the authors suggest, by arguing for rights in the case of PAS, relying on a dispassionate "liberal neutrality," which holds that neither the government nor the individual ought to get in the way of one's "considered" end-of-life decisions, including those related to PAS. And this neutrality is not merely abstract, for its chief failure lies in what it leaves out, namely, "the surrounding interpersonal context of the dying process" (242). Unsatisfied by this empty liberal formalism, the authors propose two principles: respecting the "relational integrity of the person," and protecting dying individuals from "moral trespass" (242, 245). By way of clarification - and perhaps to emphasize the deeply moral and spiritual rather than (liberal) political or somatic foundations of these concepts -- they cite Paul Ramsey's The Patient as Person, where Ramsey notes that "the sanctity of human life prevents ultimate trespass upon him even for the sake of treating his bodily life" (279). This "sanctity" includes taking seriously the social connections in an individual's life that give that life meaning. These principles, then, might enable us to move away from viewing death and dying as a triumph of the autonomous individual, asserting his or her abstract rights, and toward accepting the dignity and the interrelatedness of our mortality. This acceptance, warranted by "moral common sense" and by our shared humanity, excludes both direct euthanasia and assisted suicide.

In a number of ways, this is a brave book. It is brave because it is bound to upset a number of those who take themselves to be liberal, and because it engages with so many different areas (political theory, medical ethics, legal theory, and so on). The former worry, I think, is only partially warranted, for autonomy (and its related notions), while still arguably central to any discussion involving ethics and politics, has become somewhat of a predictable philosophical refrain, repeated, mantra-like, when we run out of original argument. Thus, while the book's treatment of Mill's harm principle (which calls for absolute liberty in matters that are purely self-regarding, justifying interference only on the basis of harm to others) might be a bit too brief and its claims about emotions and reasons may be a little light on illustrative examples, the fact remains that autonomy (and its correlative abhorrence of all coercion) calls for a fresh critique. That said, the authors' attempt should not only be encouraged, but applauded.

Although the book's multidisciplinary approach might generate concern in the current climate of micro-specialization in academe, in my view it is very welcome. Given that the arguments put forth are direct challenges to some of the most fundamental modern liberal assumptions, it appears as quite sensible, and indeed refreshing, that the authors draw on a variety of sources for their conclusions. If the subject at hand is nothing short of the nature of human good, it certainly deserves a multifaceted, multidimensional treatment. Indeed, those who might critique the book based on its academic "homelessness" might be missing the point.

Finally, a word is warranted about the new chapters in this edition. As I noted earlier, they primarily address medical ethics, broadly construed (really extending into areas of law, sociology, psychology, and so on). These additions to the text are generally successful, both in terms of the rigor of their analysis and the strength of the specific examples that are offered in support of the authors' overall claims. There are, however, several concerns that should be noted. First, a clearer, more precisely drawn connection between the "good" kind of coercion and end-of-life decisions would have been helpful. For instance, how might we address worries about the relationship between coercion and power differentials, especially in the case of the disempowered patient and the often-intimidating medical establishment in whose care she finds herself? How can the inadequacies of "liberal neutrality" be overcome, or at least be challenged, by policies that are coercive in the right way, that is, that take seriously the complexity of end-of-life decisions and their role in a good life while taking off the table certain options (such as PAS)? While the authors gesture toward "the ethic of interdependence," pointing beyond autonomy and neutrality to a more Aristotelian, inclusive, civic-minded conception of the good, some of their suggestions sound a bit like promissory notes rather than concrete solutions.

Moreover, I wonder if in their discussion of the role of the family (and other relationships) in decisions about life-sustaining medical treatments, Gaylin and Jennings did not go too far in supplanting what they view as an excessive focus on the individual with an equally polarizing claim that calls on us "to rethink the assumptions about the self that allow it to have interests apart from relationships in the first place" (227). While I am rather sympathetic to the notion of looking at the self as, in part, a function of its relations with the world, I am not sure that the authors offer a sufficiently nuanced claim. That is, are we to read them as arguing that we are nothing but the products of our relationships? But this does not seem to leave much room for personal responsibility on our part. After all, if the individual as such is insignificant apart from her relationships, then perhaps we might only hold groups morally accountable (and morally praiseworthy) instead of the singular person. This possibility, however, is less than satisfactory, and does not appear to fit with many of the other (individual-centered) claims made by the authors.

Ultimately, The Perversion of Autonomy is a powerful and significant book. It dares to take on the generally untouchable pieties of contemporary liberal thought -- autonomy and individual freedom -- with rigor, passion, and a determination to make us consider, and re-consider, the positions we might have otherwise regarded as unassailable. While its tone is at times academic and directed at scholars, it is also quite accessible to those members of the general public who are interested in politics, medicine, philosophy and current affairs. And it is this kind of socially inclusive probing, searching, and questioning that ought to be at the heart of any conversation about freedom and the human good. To this vital discourse, The Perversion of Autonomy serves as an important contribution.

Anna Gotlib, Michigan State University