Theories of Autonomy
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
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.
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
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
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.