Autonomy and Chronic Illness: Not Two Components But Many12 May 2016
Naik et al argue that ‘decisional autonomy’ is insufficient to account for nonadherence in the context of chronic illness and that what is required is a two compartment re-conceptualisation of autonomy that includes both decisional autonomy and ‘executive autonomy’. While the authors correctly point out the concentration on the cognitive aspects of competence in the bioethics and medical literature, the model of autonomy that they propose is consistent with process or discursive models of consent, and with the work of Bergsma and Thomasma,1 Gillon,2 Beauchamp and Childress,3 all of whom describe the importance of action or enactment in medical decision-making. Indeed, while autonomy is usually defined in terms of self government, it can usefully be described as being a cluster of notions that together signify control of decision-making. Included in this cluster according to Bergsma and Thomasma1 is the ability to set life-plans, and the capacity to adapt to changing circumstances. To successfully carry out a decision three functions come into play (i) autonomy of thought (ii) autonomy of will and (iii) autonomy of action. It follows then that the patients in the study described by Naik et al have autonomy of thought (occurrent aspect), and of will (intentionality), evidenced by their participation in developing self management plans, but according to Gillon,2 are deficient in autonomy of action (disposition aspect). This agrees with Beauchamp and Childress’ principles3 underpinning autonomy as being liberty (independence from controlling influences) and agency (capacity for intentional action). The primacy of autonomy in medical care has been extensively critiqued over the past two decades. Naik et al provide yet another reason to be sceptical of simplistic formulations of autonomy and decision-making in medicine. At the same time, however, we believe that the authors continue to over-emphasise rationality, deemphasise the social and relational basis of autonomy and agency, and provide an insufficiently complete model of capacity in chronic illness. As much can be seen by their description of ‘biopsychosocial correlates of autonomy’ which draws upon recent developments in neurobiology but says nothing about the social or relational basis of illness.