Philosophy, Psychiatry, & Psychology

Autonomy is an important concept in ethical and political theory and arguably a central concept in bioethics. Its implications for psychiatry are clearest in cases in which competence is at issue, but its significance for the philosophy of psychiatry is much deeper. The term autonomy admits a wide range of meanings which includes qualities such as self-rule, self-determination, freedom of will, dignity, integrity, individuality, independence, and self-knowledge. In ethical thought, it is identified with the qualities of self-assertion, critical reflection, responsibility, absence of external causation, and knowledge of one's own interest; it is also thought of in connection with actions, beliefs, principles, reasons for acting, and rules (Christman 1988, 1989; Dworkin 1988). This evidently wide range of usage of the term autonomy undoubtedly complicates the application of the term in psychiatry.

The term autonomy has its origin in the Greek autos (self) and nomos (rule, governance, or law). Its earliest use involves reference to self-rule or self-governance in Greek city-states. This original meaning of the term is still in evidence in the general idea of personal autonomy, which involves being one's own person or being able to act according to one's beliefs or desires without interference. In its commonest usage, personal autonomy is predicated of actions or thoughts that are characterized by the presence of freedom, rationality, and consistency with one's own preferences. Clearly, then, autonomy as applied to persons is a broad notion, because it involves reference not only to the individual, but also to the will, or to action in the social world. To compound matters even further, autonomy is sometimes employed either as a principle or as a value, and concepts that are central in its discussion, such as consent, paternalism, or respect for persons, themselves have a range of meanings that is partly due to their employment in different philosophical theories.

Both utilitarian and deontological traditions, for example, treat autonomy, but with different emphases. In John Stuart Mill's classic, On Liberty, autonomy is treated primarily as the autonomy of action and thought of an individual engaged in the social world; Mill's focus is on liberty or noninterference. In the work of Immanuel Kant, in contrast, autonomy is primarily treated in terms of the will; so regarded, autonomy becomes an ethical value or principle correlated to the will of an ideal or transcendental self. The best-known treatments of autonomy involve the so-called liberal tradition in political and/or legal theory, in which the autonomous person is idealized as a free, rational, agent who is able to make choices based on his own preferences. Respect for autonomy thus becomes a matter of acknowledging and honoring individuals' rights of self-determination in society. Such abstract, idealized accounts of autonomy and the rights-based ethic that they spawn might be taken to suggest that philosophical work on autonomy has, at best, a peripheral interest for psychiatry. For one thing, [End Page 267] idealized autonomy sets standards that are far removed from the everyday world of psychiatric practice; for another, idealized autonomy seems at odds with an understanding of the mature person as one who has a developed self-identity that gives substance to the meaning and scope of his unique personal sense of being autonomous. Critics of the liberal view of autonomy point out that it disconnects the self from interpersonal relationships that sustain who the free individual is and that it sets the individual as the normative standard for all matters (MacIntyre 1981). Others have stressed that one's concept of self is ineluctably formed in interaction with others and so this contribution to the actual autonomy of persons should not be ignored (Agich 1993; Bergmann 1977). Despite these criticisms, the liberal view dominates Western thought and culture; it is important for psychiatry even though estimating its significance is complicated.

In light of these points, it might be best to regard autonomy as a term that does not admit precise definition. Its meaning consists of a set of family resemblances based on its use in a variety of contexts or language games. In considering autonomy, it is always...