Autonomy and Chronic Illness: Not Two Components But Many

Abstract

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 decisionalud autonomy and ‘executive autonomy’. While the authors correctly point out theud concentration on the cognitive aspects of competence in the bioethics and medicalud literature, the model of autonomy that they propose is consistent with process orud discursive models of consent, and with the work of Bergsma and Thomasma,1ud Gillon,2 Beauchamp and Childress,3 all of whom describe the importance of actionud or enactment in medical decision-making. Indeed, while autonomy is usually definedud in terms of self government, it can usefully be described as being a cluster of notionsud that together signify control of decision-making. Included in this cluster according toud Bergsma and Thomasma1 is the ability to set life-plans, and the capacity to adapt toud changing circumstances. To successfully carry out a decision three functions comeud into play (i) autonomy of thought (ii) autonomy of will and (iii) autonomy of action. Itud follows then that the patients in the study described by Naik et al have autonomy ofud thought (occurrent aspect), and of will (intentionality), evidenced by theirud participation in developing self management plans, but according to Gillon,2 areud deficient in autonomy of action (disposition aspect). This agrees with Beauchampud and Childress’ principles3 underpinning autonomy as being liberty (independenceud from controlling influences) and agency (capacity for intentional action).ud The primacy of autonomy in medical care has been extensively critiqued over theud 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,ud however, we believe that the authors continue to over-emphasise rationality, deemphasise the social and relational basis of autonomy and agency, and provide anud insufficiently complete model of capacity in chronic illness. As much can be seen byud their description of ‘biopsychosocial correlates of autonomy’ which draws uponud recent developments in neurobiology but says nothing about the social or relationalud basis of illness