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A troubling foundational inconsistency: autonomy and collective agency in critical care decision-making

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“A moral theory that stresses the supremacy of autonomy will have difficulties with the concept of obligation.” —Gerald Dworkin [1 p. 81]

Abstract

‘Shared’ decision-making is heralded as the gold standard of how medical decisions should be reached, yet how does one ‘share’ a decision when any attempt to do so will undermine autonomous decision-making? And what exactly is being shared? While some authors have described parallels in literature, philosophical examination of shared agency remains largely uninvestigated as an explanation in bioethics. In the following, shared decision-making will be explained as occurring when a group, generally comprised of a patient and or their family, and the medical team become a genuine intentional subject which acts as a collective agent. Collective agency can better explain how some medical decisions are reached, contrary to the traditional understanding and operationalization of ‘autonomy’ in bioethics. Paradoxically, this often occurs in the setting of high-stakes moral decision-making, where conventional wisdom would suggest individuals would most want to exercise autonomous action according to their personally held values and beliefs. This explication of shared decision-making suggests a social ontology ought to inform or displace significant aspects of autonomy as construed in bioethics. It will be argued that joint commitments are a fundamental part of human life, informing and explaining much human behavior, and thus suggesting that autonomy - conceived of as discrete, individuated moral reasoning of a singular moral agent - is not an unalloyed ‘good.’

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Notes

  1. Italics added.

  2. As of this writing, Russia has been forcibly occupying Crimea since 2014 following a purported referendum in which Russia reportedly won 95 percent of the vote.

  3. Italics added.

  4. Italics added.

  5. Tom Beauchamp makes such a case in “Methods and principles in biomedical ethics” (2003) arguing that if one autonomously submits to an authority, their actions as dictated thereafter by that authority are also autonomous. (p. 270) The error here is in considering the autonomous act of submission to range over all that follows. It is perfectly possible that a person does not even consider whether or not premise t justifies act x, and merely acts x because the authority expects x. In such a situation, none of the reasons for valuing autonomy to begin with are present; the individual is not choosing to x based on a rational deliberation over the merits of x, because x aligns with one’s life projects, or x’s intrinsic or instrumental value, or x’s accordance with personal beliefs or values. Thus the more subsequent the acts are to the submission, the more vacuous such an interpretation becomes.

  6. Emphasis added.

  7. Emphasis added.

  8. Statement by Yoram Unguru during the Stanford Leikin Memorial Lecture. Children’s National Medical Center. 2016.

  9. Gilbert cites: Rousseau, Jean-Jacques. The Social Contract and Discourses. (orig. 1792). D.A. Cress (trans.). Indianapolis, IL; Hackett; 1983: 23.

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Teti, S.L. A troubling foundational inconsistency: autonomy and collective agency in critical care decision-making. Theor Med Bioeth 44, 279–300 (2023). https://doi.org/10.1007/s11017-023-09608-4

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