Wednesday, February 01, 2012

Autonomy and Dignity

Christopher Kaczor recently had an article on human dignity at "Public Discourse", addressing Steven Pinker's 2008 article on the same subject. When Pinker's article came out I blogged about it and was not impressed. But it's worth revisiting, and MrsDarwin asked my thoughts on the concept of autonomy in the article, which I hadn't really addressed at all before. So I'll throw out a few things on the subject.

Throughout his essay, which is titled, "The Stupidity of Dignity," Pinker attacks the notion of human dignity, arguing that the notion of autonomy is morally superior and more useful. This is at first glance a puzzle, since anyone who knows the history of the two concepts knows that they have always been pretty closely connected. What Pinker is actually doing is building on an argument in an article on bioethics by Ruth Macklin, called, "Dignity is a Useless Concept." To put the argument of that work very roughly, Macklin argued that dignity was a useless concept because everything significant that you could do with an appeal to human dignity could be better done simply by appeal to the principle of autonomy -- that, in fact, most of the work done by such appeals to human dignity were just obscure appeals to the principle of autonomy, anyway. If you can talk of autonomy, talk of dignity is redundant.

I don't know much about Macklin's other work, but I think the argument in that editorial is extremely poor. We see this in several ways. For one thing -- and this has been noted by bioethicists since Pinker wrote his essay -- Macklin doesn't really do justice to the possibility that 'dignity' is in fact a genus, of which autonomy is merely one species. There are other principles besides autonomy that come up when we talk about human dignity. To take just one, the principle of common human sympathy, that we should take into account not just people's capacity to choose but their feelings regardless of what they choose, is something that comes up in medical situations. It is not, however, a part of most common accounts of autonomy, which is about reason and choice, not about feeling. And it may not be as important as autonomy for bioethics. But it is something people do tend to think important, and when asked why it can't simply be cut out, people will talk about it in terms of the dignity, or worth, or value of the other person. But even if we don't consider such things, dignity is not a concept confined to bioethics; it is applied far more generally -- indeed, far more generally than autonomy -- to situations like the plight of the poor and oppressed. And it is clear in many of these cases that autonomy is not that the only thing on the table, e.g., solidarity is important, and so forth. At best Macklin's argument could only apply within the field of bioethics -- at best it can be an argument that the only dignity-concept to be considered in bioethics is autonomy. I think this is false, of course, but even at best Macklin's argument can't rule out the possibility that it is crucially necessary for discussing how bioethical issues relate to issues outside of bioethics -- as one might well need to do in popular work or for purposes of public policy.

And note: it doesn't even matter if autonomy is in fact the only dignity-concept useful for bioethics itself. It is clear that many people deny that it is, and argue that other things should be considered. These disputes can only be adjudicate in light of more general concepts than autonomy itself -- such as the concept of human dignity.

And human dignity is the more general concept. We can see this when we recognize that autonomy need not be taken as normative -- that is, you could simply go around identifying some things as autonomous without regarding this as particularly significant for anything. The concept as used in bioethics has greater weight, implications for practice. What makes the difference? That when we use it in the latter way, we are treating autonomous agents as having worth, value, precisely as autonomous agents: namely, dignity.

We see this historically, as well. Human dignity was a big topic of discussion in the eighteenth century. There are a number of notable works that at least discuss the subject in this period, such as Georg Joachim Zollikofer's famous series of sermons on the dignity of man. (Worth reading, by the way; they are famously eloquent, and like a lot of eighteenth century sermons do at times get into serious philosophical questions, albeit in a popular way.) Zollikofer's actually pretty interesting; he lists autonomy-type things (freedom, etc.) as part of what constitutes human dignity, but his idea of it is not so narrow, since human dignity covers everything that is required for a fully human pursuit of happiness. Not only is autonomy important, but also virtue, the relation of a human being to his or her Creator, the capacity for moral and intellectual progress, all are mentioned. And I don't think Zollikofer is really arguing anything out of the ordinary for the time, either. Autonomy itself only becomes truly important as a moral concept with Kant, and closely reading the passages on autonomy in Kant shows clearly that he himself treats autonomy as equivalent to dignity. That human beings have autonomy is itself why human beings are beyond price. They have neither market price nor emotional price (merely sentimental value) but are truly priceless -- they have dignity. To treat autonomy itself as being of any special significance, Kant has to connect it with more general and common considerations of human dignity; and in the contrary direction, when Kantian-minded pastors (of whom there were quite a few in the late eighteenth century) wanted to speak to their congregations of Kantian moral questions, would do so in terms of human dignity, the more generic because less technical concept.

Both Macklin and Pinker, however, really gloss over the important fact that in this day and age, even if you confine yourself to autonomy, there is nothing that is the principle of autonomy. Rather, there are many different accounts of autonomy. And many of the ethical disputes that occur can be recognized to involve differing conceptions of autonomy. For instance, do children have autonomy. There is a pretty straightforward sense in which children are highly heteronomous: they are in the care of parents and guardians, and they are not generally regarded as competent for making major decisions on their own. That is what heteronomy is. But one could have a looser sense of autonomy in which they do count as autonomous, in the sense that they have capacity for actual autonomy. The same thing goes for people with serious mental deficiencies. Nobody is obviously autonomous if they are not making their own decisions; and, of course, it is simple nonsense to suggest that doctors never have to deal with patients who aren't making their own medical decisions -- can't, in fact, make their own medical decisions, whether legally or mentally. In order to hold that doctors have any obligations to children, if you are doing so not on the basis of something like dignity, some value children have regardless of their capacity for choice, you need a pretty broad and loose account of autonomy. And this is going to give you very different results than a stricter account of autonomy will.

What account of autonomy do we find in Pinker's essay? Here are some things he says about it:

The volume contains fine discussions by Pellegrino and by Rebecca Dresser on the avoidable humiliations that today's patients are often forced to endure (like those hideous hospital smocks that are open at the back). No one could object to valuing dignity in this sense, and that's the point. When the concept of dignity is precisely specified, it becomes a mundane matter of thoughtfulness pushing against callousness and bureaucratic inertia, not a contentious moral conundrum. And, because it amounts to treating people in the way that they wish to be treated, ultimately it's just another application of the principle of autonomy.

Notable points here: autonomy is here reduced to "treating people in the way that they wish to be treated".

Note, though, that all these cases involve coercion, so once again they are ruled out by autonomy and respect for persons.

Notable points here: autonomy is here linked to noncoercion.

And we get some vague comments about freedom that are probably intended to link up with autonomy, too. Notice that, despite Pinker's loud proclamation of the lack of definition and the squishiness of the concept of dignity, we don't really get a definition of autonomy here, and it itself is very squishy. Treating others as they want to be treated is obviously something that has important limits. Noncoercion may be important, but obviously in medical situations you are often going to come into situations where it will be tricky to determine whether something is coercive. Doctors have to communicate with patients, for instance. How a doctor does so can have a big effect on the course of treatment; how far can a doctor go in presenting the case for a treatment before it starts to endanger this noncoercion requirement? Doctors have to make very quick judgment calls at times. How far can a doctor go in deciding on their own on a course of action in such situations before they are acting in a coercive way? And notice that it's completely unclear from anything Pinker says whether children are to be considered as autonomous. We don't in any strict way treat them as they want to be treated; we don't in any strict way avoid coercing them. They are, again, in a pretty straightforward sense heteronomous, and don't have a full slate of social freedoms. That would seem to rule them out. But Pinker never tells us. Like lots of autonomy theorists, he forgets that children exist (they are mentioned once in the essay, in a completely incidental way). The same thing again occurs with people who have significant mental disabilities (the only time Pinker mentions them in the essay it is simply to say that we read in discussions of dignity that everyone, no matter how lazy, evil, or mentally impaired, has dignity). Again, Pinker, like many autonomy theorists, has completely left out adults who are in very obvious ways necessarily heteronomous. And yet we are told over and over again that autonomy doesn't leave anything out. At one point Pinker uses the phrase "autonomy and respect for persons". Is this a hendiadys? it must be, or Pinker has just introduced a second principle that is relevant to questions of dignity -- autonomy wouldn't be enough if you also have to appeal to a principle of respect for persons. But the two don't seem to be synonymous. For one thing, respect for persons obviously includes respect for heteronomous persons.

I actually suspect that Pinker's notion of autonomy has no opposite. Autonomy properly means that one is capable of legislating, making law, for oneself. But it simply does not seem to occur to Pinker that anyone could be in situations where they can't actually be treated as autonomous because they are not able to make their own decisions. Children and people with mental disabilities either don't exist in Pinker's world -- or autonomy becomes such a broad principle that it no longer means autonomy. Indeed, it is no longer clear what it means.

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