Fast Takes

Bruce L. Miller.  "Autonomy and the Refusal of Lifesaving Treatment."  Hastings Center Report 11(4):22-28, 1981.

This classic paper by an MSU philosopher begins by reviewing four cases in which a patient refuses lifesaving treatment, and physicians might wish to overrule the refusal to save the patient's life.  Miller states that physicians are obligated to respect treatment refusals by autonomous patients.  But "autonomy" is an ambiguous concept and could be used in several different senses.  He then suggests four senses of autonomy that might be relevant to medical decisions:

Free action: A patient is autonomous in this sense if the choice is both voluntary (uncoerced and free of undue influence) and intentional (the person's conscious object).  This sense of autonomy is captured by the "minimal" legal doctrine of informed consent-- the patient must be told what you plan to do to him and he must freely agree to it.  It is not undue influence to try to persuade someone to act differently so long as you use no deception or manipulation.
Authenticity: The patient is autonomous in the sense of authenticity if the choice made is consistent with the patient's attitudes, values, and life plans, as these have been shown to be reasonably stable over time.  An authentic decision is "in character" for the patient.
Effective Deliberation: A patient is autonomous in the sense of effective deliberation if she is aware of the need for a decision, the alternative courses of action, and their pros and cons; she evaluates all the options in light of her personal values; and chooses the best option for her based on that evaluation.  The patient, to effectively deliberate, need not question or re-examine her own values, but need merely apply them to the options at hand.  This sense of autonomy perhaps come closest to the "ideal" or "full" legal doctrine of informed consent.
Moral reflection: A patient is autonomous in this sense if he consciously and critically examines his values and decides whether or not to continue to live in accord with them in the future.  Since most of us most of the time simply act from the values we received as part  of our growing up or acculturation process, without critical re-examination, this sense of autonomy may be seen quite rarely in clinical practice.  (But see the article by Emanuel and Emanuel on why the physician might be obligated to try to promote this sense of autonomy.)

Miller next shows by case analyses how patients might demonstrate some senses of autonomy while lacking others. Miller is relatively silent on criteria for respecting autonomous choices except to indicate that no choice which is not a free action can be respected as truly autonomous.  He suggests that patient choices may lack authenticity, effective deliberation, and moral reflection, and yet physicians might still be obligated to respect those decisions.  But if a patient is choosing without authenticity or effective deliberation, the physician might have a stronger obligation to question the decision and to try to enhance the patient's autonomous capacities before the final decision is made.

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