Theories of Autonomy
Michael A. Gillette, Ph.D.

Appeals to privacy and autonomy, as seen in last month's discussion of reproductive freedom, are often the most powerful tools that we have when we wish to protect our own freedom of action. If I decide that I want to live my life in a certain way, and you feel that my personal choices are incorrect, I can respond in two possible ways. First, I might tell you that the decisions which I make are "none of your business". Second, I might argue that while my decisions are legitimate areas of concern for you, I am the final authority for making decisions that effect my life.

The first argument, which we might call the N.O.Y.B. argument for "None Of Your Business", is commonly employed. When I decide how to spend my money, for instance, I do not necessarily want you to comment. If I want to buy something that is completely useless, and perhaps even ugly, it is my decision and no one else's. If you subsequently come to my home and see that I have purchased a poorly crafted brass door stop which is in the shape of a large fish, it is appropriate for you to keep your comments to yourself. If you did have the audacity to comment on the wastefulness of spending money on such an object, I can fairly reply with the standard N.O.Y.B. argument.

The N.O.Y.B. argument does have its limitations, however. There are many situations in which my decisions are not mine alone. If, for instance, I spent the last of the rent money on the offending doorstop, then my spouse, who will be evicted along with me, has every right to criticize my spending habits. If I reply by saying "N.O.Y.B.", my spouse may answer that she is minding her own business, because my choices have impact on her life.

The limitations of the N.O.Y.B. defense in the clinical setting are clear. If a staff person refuses to act in accordance with medical orders, for instance, the N.O.Y.B. argument is inappropriate. The welfare of the patient is at stake in this situation and the clinician cannot feasibly maintain that it is simply a matter of personal preference for the staff member whether or not he/she does his/her job.

There are gray areas, however. Suppose that a client refuses to accept treatment that is clearly medically indicated. Can the client respond to pressure from staff by saying N.O.Y.B.? Providing appropriate care to our clients is our business. Therefore, when a client refuses care, he or she seems to be forcing us to change the way we view our own jobs.

Once arguments have been reached, a common second move is to employ an argument from autonomy. The client in the above example might respond by saying that while it is true that his/her treatment decisions effect others, and are therefore part of other people's business, the person who must make the final decision in such cases is the client him/herself. Of course in the CVTC environment, we commonly assume that clients are not capable of making such decisions, and we would then defer to the authorized representative.

The argument from autonomy rests on the assumption that people have a basic right to make their own decisions regarding their own lives, even when those decisions might make other people unhappy.

The immediate difficulty with the autonomy argument is that it, too, has its limitations. We do not allow criminals to autonomously choose their own plans of life precisely because their choices hurt other people. Even when the only person involved is the autonomous decision maker, we often interfere. This is indicated by legislation in most states which makes suicide illegal.