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Theories of Autonomy

Reproductive Freedom II
Michael A. Gillette, Ph.D.

This document and the ideas presented herein are the intellectual property of Bioethical Services of Virginia, Inc. and may be used and reproduced only with proper citation.

In the last issue of this newsletter, we discussed an argument which was designed to show that forcible sterilization is not as easily justified as was believed fifty and sixty years ago. Thankfully, the eugenics programs that flourished in the United States over a half a century ago have long since been eliminated. However, we must wonder if we have moved too far in the opposite direction. Have we inadvertently created an environment in which the best interests of some individuals with mental retardation are not secured precisely because we refuse to permit forcible sterilization?

Consider the case of a thirty year old man and woman, both of whom have mild mental retardation, but who love each other and want to live together as husband and wife. Let us assume that the couple does understand the likely results of their sexual activity and that they have specifically noted a desire to have children together. Let us also assume that they have been ruled by a court to be incompetent to make their own medical decisions and that their respective parents, acting as their guardians, are willing to permit the marriage but do not want to take any chance that the couple will have children.

An argument has been presented in the philosophical literature that would support the use of surgical sterilization in this case, all other things being equal, even over the objections of the man and woman themselves. The reason that I must note "all other things being equal" is that an obvious first step in examining this case must include a discussion of the goals that the parents wish to achieve for their children, as well as the possible alternative methods for achieving those goals.

We must learn why the parents of this man and woman are willing to let them marry, but not willing to let them have children. Have the capacities of these people been properly determined and are the parents truly acting out of a concern for the best interests of their children and possible grand-children? The possibility of initiating the use of a contraceptive like Norplant would seem to be a desirable option over the prospect of sterilization without patient consent.

Even if Norplant were an option, however, that would not solve our problem. Norplant is reversible, so the impermanence of using such therapy relieves much of the difficulty. Nevertheless, we must still wonder whether forcible drug therapy in such situations would be ethically permissible itself. The very same issues regarding individual rights would crop up when drug therapy is utilized against a person's will rather than surgery. case. We can safely assume that similar ethical issues will arise whichever option we choose from among the available treatment alternatives.

Robert Neville argues carefully in "Sterilizing the Mildly Mentally Retarded Without Their Consent: The Philosophical Arguments" that the above outlined case is a prime example of a situation in which non voluntary sterilization is morally appropriate. (This article appears in a book entitled Mental Retardation and Sterilization which is available in the Ethics Office, Bradford Building)

Neville argues that if the goal in working with people with mental retardation is to provide them with as normal a life as possible, complete with the autonomous control over as many life choices as possible and the freedom to maintain a healthy sex life, then sterilization will provide the greatest benefit. By reducing autonomy in one area of these people's lives, we actually increase the overall capacity of these individuals to live substantially autonomous existences. In other words, a little loss of autonomy now is worth experiencing if it will generate a greater freedom later.

It is important to notice that Neville is not arguing as people did sixty years ago. He is arguing out of concern for the best interest of the individual with mental retardation, not on the basis of overall social good. That fact makes the argument much more reasonable to many. In fact, the argument seems compelling. We all accept short term pain (inoculations) for long term benefit (avoidance of disease). If the argument works in most cases, why won't it work in these cases as well? If my only other alternative is to deny the two people in our example the opportunity to live together in a loving relationship, and perhaps to keep these two people physically separated, is it not best to select the option of allowing them some measure of a normal romantic involvement even if that entails denying them the opportunity to have children?

While I do not wish to argue that Neville's points are without merit or that they must obviously be false, there is one significant counter-argument to consider. Is autonomy the sort of thing that can be traded off from one day to the next? Is autonomy the sort of thing that we are merely attempting to maximize over time, or is it the inviolable right of human beings to be honored in their autonomy, come what may?

We find in this discussion, as in most ethical disputes, the need to think theoretically about the conflict between inalienable rights and expediency. The next step then, in determining the merit to Neville's view, would be to consider the extent of the right to bodily autonomy and the right to reproduce.

 

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