anafsheh B Sharif-Askary Pubpol 155 October 25, 2010 Reflection #4: Is there such thing as autonomy? Though it has manifested through the years to take on new roles, the concept of autonomy is in no way a novel. Some of historys greatest philosophers believed that each human being is special because they are able to make reasoned judgments and decisions, thus exhibiting some level of personal responsibility or autonomy. A German philosopher Immanuel Kant forwarded one of the most interesting theories of autonomy. Kant believed that each person demonstrated their autonomy by making choices in line with their moral duty. To Kant this autonomy gave each human being a sense of self which was established by moral goodness. Kant wanted to universalize some idea of autonomy and to do so he tried to base his ideas on some universal concept such as personhood. Kant and other philosophers discussion of autonomy spread the concept and very quickly it became a more common ideology. Now the concept is very pertinent to many societies throughout the world, some however, more than others. For the countries in which autonomy has become a fundamental aspect of the social, legal and political systems, the concept is very real and relevant in the way people lead their lives; including their health care decisions. However, many challenges arise to a true sense of autonomy in the world of global health. The concept of autonomy is rather universal when we look at contemporary international law as a standard of evaluation. We must first evaluate the saturation of power in the major forums of international law (UN, ICC, etc..) The major powers in the world of international law tend to be Western countries, which respect a concept of autonomy inherently and therefore transfuse these ideas into the international
law. Three (United Kingdom, USA, France) of the permanent members of the UN Security Council are from countries with societies which respect a notion of autonomy in their society and law. The United States, arguably the country, which holds the most weight in the UN, has a society, which is firmly held together (both in law and in belief sets) by a notion of autonomy. Because many of the more powerful countries in the UN have societies which inherently respect a notion of autonomy, much of the actual content (law, declarations, etc..) that comes from the UN has safeguards and clauses respecting autonomy. The Nuremberg Code, a set of research ethics written in response to the war crimes of WWII by Nazis, had an entire portion devoted to developing a sense of autonomy. The first principle in the code defines how the person being researched should be treated: (the) person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud By explicitly outlining how the patient should have the legal capacity to give consent and exercise free power of choice, the writers of the Nuremberg Code (The International Military Tribune) are outlining a sense of autonomy for persons with regards to medical research in law. Interesting challenges to a concept of autonomy in medical care are found in the US when religion gets in the way of healthcare. The Christian Scientist faith believes that their creed-based healing system should be used rather than medical treatments or drugs. The notion of freedom of religion, similar to many other freedoms under law, can trace its roots back to the notion of autonomy. As a person, the Christian Scientist should be able to choose how to deal with their medical issue and make the choice not to use drugs
or other any conventional form of Western medicine. However, US law in some cases such as this strange instance contradicts autonomy and puts restrictions on decisions that are malevolent. In most states it is illegal to neglect the health care of a child by only using spiritual methods that are associated with a religion while ignoring physicians considerations. On the surface this law seems to violate our conception of autonomy is: the ability to make our own choices. But if we refer to what Kants philosophy in regards to autonomy states that our decisions must be guided by a sense of moral duty to goodness. Thus, by neglecting a child one is not fulfilling their moral duty. Therefore, the US law is in fact setting up a safeguard for a real sense of autonomy in the way that Kant viewed it. If the United States is considered to be one of the worlds most civilized places and if we are such an unbelievable example of how to run a country how is it that we have over forty-five million citizens who dont have health insurance? How can you have true autonomy in health care when you have absolutely no way to pay for the treatments and drugs that you need without insurance? As I said, the United States is considered to be one of the most adamant supporters of a sense of autonomy and equal moral worth, especially in law. Still, a staggering number of citizens cant make choices with regards to health care. People cant pay for medical treatment, drugs or in this case healthcare insurance, and thus there is an inherent lack of autonomy. The United States poverty is a challenge to autonomy in health care however this challenge can be expanded to a universal sense of autonomy of decision in terms of health care. If we look at the issue of poverty as a challenge to autonomy in some of the poorest countries in the world it is simple to see that in order to ensure that freedom of
choice in decision with regards to medical treatments, drugs, etc..we must close the gap in wealth in these countries. In my work this summer in Uganda I noticed how much harder it was for Ugandan patients to exercise free choice in their health decisions. While working at the Mayanja Memorial Hospital, I noticed how the equipment was rudimentary and realized that it must be miracle that anything gets accomplished. To warming the babies after birth, the nursing staff only had a rusty lamp on a stool. The microscopes used to check blood for signs of malaria are analogous to the ones used in elementary school to look at cheek cells. The basic equipment was all that this hospital had the money to buy and even the equipment they did have often malfunctioned. The same basic drugs were used by all patients, with no deviation from the standard even when it was necessary. Basic survival is the focus in these countries, not autonomy. Each person has a right to live and a right to make choices and be autonomous, however when there is not enough money to foster a society which respects autonomy, survival is the focus. Although the international community has universally accepted the idea of autonomy in law, many challenges pose a threat to all humans ability to make free choices guided by a sense of moral duty. Kant and other philosophers idealized notion of what autonomy is has guided a universal charge to give all humans personhood. However many issues, like economics and poverty, threaten our ability to guarantee autonomy to all. An idea of autonomy certainly exists in contemporary society, both in law and in belief systems, but for this idea to truly exist, especially in the global health world, steps must be taken to reduce the monetary disparities in our world.