J. Alan Branch
Introduction
On June 29, 1992, the United States Supreme Court delivered its ruling in Planned Parenthood of Southeast Pennsylvania v. Casey, a case revolving around certain regulations in Pennsylvania law that mandated waiting periods for abortions as well as parental consent for minors seeking abortions. By a 5-4 decision, the court upheld the core holding of Roe that women have the constitutional right to choose an abortion, though the Casey court did allow states more latitude in regulating abortions.1 The Casey decision shifted the basis for abortion rights from a questionable right to privacy to the more explicit liberty interests of the fourteenth amendment. Writing for the majority, Justices David Hackett Souter, Anthony M. Kennedy, and Sandra Day O’Connor defined liberty protected by the Fourteenth Amendment to include those matters “involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment” (Casey 851). The Court went on to say that the type of autonomy they envision includes “the right to define one’s own existence, of meaning, of the universe, and of the mystery of human life” (Casey 851).
The Court’s reference to autonomy reflects the broad appeal of autonomy in bioethical debates. While autonomy rarely was mentioned in medical ethics prior to World War II, the second half of the twentieth century saw it supercede other principles in many debates. When confronted with ethical dilemmas, ethicists have focused on questions such as “Is this person making an autonomous decision?” and “What capacities are needed for a person to make an autonomous decision?” Why has autonomy achieved such an exalted position in medical ethics? Two significant factors have contributed to the rise of autonomy: the exponential growth of medical technologies and the general societal shift away from concepts of moral absolutes. Some have heralded the arrival of autonomy-driven medical ethics as a new era of respect for the patient in contrast to an older system of medical ethics that was more paternalistic. On the other hand, contrasting voices, evangelicals in particular, have sounded an alarm and declared the imminent implosion of autonomy-based health care ethics. To compound the problem, the debate can be confusing because people from vastly different perspectives use the term autonomy in diverse ways. Contrasting uses of the term can be seen if one compares Tom Beauchamp and James Childress with Jack Kevorkian. Beauchamp and Childress, in Principles of Biomedical Ethics, understand the principle of autonomy to be a necessary, but not sufficient, component of a system of biomedical ethics which also includes the principles of nonmaleficence, beneficence, and justice. Kevorkian, however, advocates a more radical, unrestrained notion of autonomy which he makes the sole basis for medical ethics. Speaking at the National Press Club Luncheon in 1996, Kevorkian described his view as follows: “Absolute personal autonomy. I’m a personal autonomist. Do and say whatever you want to do and say at any time you want to do or say it, as long as you do not harm or threaten anybody else’s person or property” (qtd. in Beckwith 223).
These contrasting approaches to autonomy illustrate the problem one faces when discussing autonomy in the health sciences and medical ethics: Beauchamp/Childress and Kevorkian affirm autonomy but qualify it differently. Beauchamp and Childress state that autonomy is “not a univocal concept in either ordinary English or contemporary philosophy” (121). Indeed, I contend that confusion exists in policy debates in the health sciences and medicine because this one term, autonomy, is used in a multifaceted way. In order to clarify the different ways the word autonomy is used, I propose that three distinct forms of autonomy can be distinguished in policy debate: partial moral autonomy, civil autonomy, and libertarian autonomy. I will summarize these three forms of autonomy and offer a brief theological critique of each one. I will present the case that an evangelical analysis actually affirms partial moral autonomy and civil autonomy. However, when evangelicals criticize autonomy, they lump notions of libertarian autonomy together with partial moral autonomy and civil autonomy. That said, I will show that in public policy debate in the United States, libertarian autonomy is the principle used by leading ethicists and is the philosophical basis for certain crucial court decisions. I will argue that theories of medical ethics based on notions of radical autonomy actually diminish freedom.
Partial Moral Autonomy
Partial moral autonomy is not an unrestrained freedom but asserts the right of each person to choose his or her own course of action within boundaries of accepted standards and norms. Thus, partial moral autonomy protects the right of a person to choose but limits the choices an individual may make. At the broadest level in society, this seems to be the type of autonomy assumed by the U.S. Constitution.2 When one speaks of government and laws, a certain worldview and approach to morality is assumed, primarily one which asserts that certain actions are wrong and should be declared illegal with appropriate repercussions for breaking these laws. People are free to choose their own course for life, yet government and laws exist in order to “insure domestic tranquility” and “secure the blessings of liberty” (U.S. Constitution, preamble). Therefore, certain actions are proscribed for the good of the entire community. This tension in American civics about concern for individual liberty and the good of the entire community is mirrored in modern debates about autonomy in the health sciences and medicine. For example, a group of essays titled “Individualism & Community: The Contested Terrain of Autonomy,” appeared in The Hastings Center Report in 1994. One contributor, Thomas Murray, pointed out the weakness of an unbridled autonomy in the face of concerns for the whole community when he said, “When autonomy is the answer, the question is largely limited to asking whether the person decided freely. Autonomy counsels us not to ask if the decision was wise, or even good in the short run for the person making it” (Murray 32).
What I call partial moral autonomy appears to be advocated in some way by Onara O’Neill. In Autonomy and Trust in Bioethics (2002), she advocates what she calls “principled autonomy” which appears to be a form of what I call partial moral autonomy. O’Neill differentiates “principled autonomy” from more radical notions when she says, “If we view individual autonomy as mere independence, its merits will be highly variable” (25). Her suggestion is to act on universal principles similar to the categorical imperative advocated by Kant.
The “four principle” approach of Beauchamp and Childress is also an example of a system of medical ethics based on a form of partial moral autonomy. While they insist that autonomy is essential to any well-developed system of medical ethics, they also argue that the principles of nonmaleficence, beneficence, and justice are necessary. These principles are part of what they describe as common morality: “The common morality comprises socially approved norms of human conduct. For example, it recognizes many legitimate and illegitimate forms of conduct that we capture by using the language of ‘human rights.’ The common morality is a social institution with a code of learnable norms” (6). Beauchamp and Childress understand that a patient’s autonomy is not unlimited but restrained by other competing and important principles.
Is partial moral autonomy consistent with the Christian worldview and the witness of Scripture? Partial moral autonomy raises anthropological issues related to the ability of people to choose and deep questions regarding what it means to be human. The heart of Christian anthropology is the doctrine of the imago Dei, the “image of God.” Thus, this doctrine seems to be the correct starting point for an evaluation of partial moral autonomy. Nigel Cameron reflects the importance evangelicals place on the imago Dei in medical ethics when he says, “The key to the Christian understanding of human nature lies in the idea of the imago Dei. Mankind—male and female—is made in that image. It is this which constitutes human being from the divine perspective; and here lies the source of the inestimable dignity of the human creature” (172). While the discussion of what it means to be created in the image of God is immense, I want to make four affirmations about the imago in reference to analysis of partial moral autonomy. First, the imago is real (Genesis 1:26) and is an essential characteristic found in all people.3 The imago is coextensive with all humanity and is essentially spiritual and non-corporeal in nature. The second affirmation I propose is that the doctrine itself implies moral accountability. The structure of Genesis 1 emphasizes the uniqueness of humanity, with man’s creation taking place on day six after all other forms of life have been created. Furthermore, only humanity is said to be in “God’s image,” thus differentiating humanity from animals. Genesis 2:17a amplifies moral accountability for humans for only Adam is given a moral imperative: “You must not eat from the tree of the knowledge of good and evil.” 4 The third affirmation is that the primary function related to the imago is the exercise of dominion (Genesis 1:28). Finally, I propose that though the imago is a substantive aspect of every human, it has also been marred by a historic, space-time fall. As a result, man is now in a condition of depravity. Carl F. H. Henry’s description of the imago in postlapsarian man as created and sullied fits with my approach to depravity (159).
With these affirmations about the imago in mind, what critiques can be made of the exercise of partial moral autonomy in relation to the health sciences? At its core the doctrine affirms the idea that each person is indeed morally responsible for making right choices. The God-given ability of an individual to ask the question “What ought I to do?” demands the capacity to decide and act on a decision.5 The Bible presents numerous occasions when people were presented with various alternatives and had the moral free agency to choose among them. The ethical challenge is to make choices consistent with God’s transcendent sovereignty. The ability to do so is impaired by human sinfulness—man’s inability not to sin. Christian eschatology also stresses that all of humanity will be held accountable for the moral value of the choices they have made (Matthew 25:31-46).
With the health sciences in mind, the concept of the imago as created and sullied leads me to conclude that a certain form of partial moral autonomy is not only consistent with Christian ethics but is indeed demanded by Scripture. Thus, I contend that evangelical author John Frame goes too far when he says, “The word autonomy should be rejected, since it almost invariably connotes lawlessness, which is the opposite of man’s responsibility to God” (38). Frame seems to imply that all uses of the word autonomy imply abandonment of moral absolutes. This illustrates one of my main points: Evangelicals tend to lump all forms of autonomy together with libertarian autonomy. As I will show later, I too reject libertarian autonomy as completely inconsistent with Scripture. Yet, Scripture does hold humanity’s freedom and accountability in tension. In fact, immediately after rejecting the word autonomy, Frame goes on to affirm what I call partial moral autonomy when he says, “But the idea that competent persons under God have the right to make their own decisions about medical treatment is certainly scriptural” (38). Frame and I agree that the freedom to choose is real, though not absolute. I call this partial moral autonomy, while he rejects any use of the word autonomy in medical ethics as inconsistent with Scripture.
Civil Autonomy
Civil autonomy refers to the right of an individual to be free from coercion when making choices. Freedom from coercion is the minimal principle for the respect of autonomy in that people ought to have independence; that is, they should be free from being compelled to participate in activities harmful to themselves. Civil autonomy received marked interest after the atrocities of World War II and the unethical research practices of certain studies within mainline medicine, such as the infamous Tuskegee experiments on black men with syphilis in Alabama. Thomas Murray summarizes these concerns as follows: “In the development of bioethics, autonomy emerged as a powerful protest against evil and thoughtless researchers and paternalistic physicians” (32). Because of the emphasis on non-coercion, civil autonomy naturally addresses the exercise of freedom. In the health sciences, this also brings to mind issues of informed consent and the diminished capacity of research subjects or patients. Informed consent, a principle which emerged in the late 1950s as courts attempted to respond to the challenges posed by the new life-sustaining technologies, is a key category of civil autonomy. Beauchamp and Childress argue that there are two uses of the term informed consent. The first sense refers to an autonomous authorization by individuals of a medical intervention or of involvement in research. They state, “An informed consent in this first sense occurs if and only if a patient or subject with substantial understanding and in substantial absence of control by others, intentionally authorizes a professional to do something” (143). The second sense of informed consent refers to institutional rules and guidelines that are legally required before a physician may provide therapeutic procedures or research. This second sense differs from the first in that the emphasis is on institutionally or legally effective authorizations.
Diminished capacity follows closely on the heels of informed consent in a discussion of civil autonomy and non-coercion in medicine and research. It is generally agreed that patients’ best interests are served when they understand their medical situations and participate in treatment decisions. Challenges come, however, when patients or research participants are unable to exercise their capacity to understand information or make decisions. Writing in the early 1980s, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research identified three elements necessary for sufficient capacity: possession of a set of values and goals, the ability to communicate and understand information, and the ability to reason and deliberate about one’s choices (57). Obviously, some patients do not meet these requirements because of age, lack of consciousness, or mental retardation. Yet, how does one determine exactly who lacks capacity? The President’s Commission offered three alternatives: the outcome approach, the status approach, and the functional approach. The Commission flatly rejected the outcome approach which bases a determination of incapacity primarily on the content of the patient’s decision. Under this approach, a patient who makes a decision inconsistent with prevailing standards is declared incapacitated. The commission also rejected the status approach. This paradigm uses particular categories to define who is incapacitated. The President’s Commission dismissed the status approach because some groups defined as incapacitated may actually be able to demonstrate capacity to a certain degree. For example, older children can make at least some health care decisions. Finally, the Commission affirmed the functional approach for determining incapacity, describing their rationale as follows, “What is relevant is whether someone is in fact capable of making a particular decision as judged by the consistency between the person’s choice and that individual’s underlying values and by the extent to which the choice promotes the individual’s well-being as he or she sees it” (171). They went on to qualify their position, saying that there are certain categories of people who are actually incapacitated because of their status, such as children under fourteen, the grossly retarded, and the comatose. Regarding impaired capacity, they commented, “Even people with impaired capacity usually still possess some ability to comprehend, to communicate, and to form and express a preference” (172).
Where does a theological critique of civil autonomy begin? Quite simply, it begins with the Bible’s condemnation of coercive acts. Because of the immense value placed on human life (Genesis 9:6; Exodus 20:13), the Bible records God’s condemnation of coercive acts by a stronger party against a weaker party. Central to this condemnation is the biblical principle of justice. Isaiah 1:17 states, “[L]earn to do right! Seek justice, encourage the oppressed. Defend the cause of the fatherless, plead the case of the widow.” Isaiah goes on to criticize systemic oppression of the weak: “Woe to those who make unjust laws, to those who issue oppressive decrees, to deprive the poor of their rights and withhold justice from the oppressed of my people, making widows their prey and robbing the fatherless” (Isaiah 10:1-2). Protective justice is also encouraged in the Pentateuch: “Do not deny justice to your poor people in their lawsuits” (Exodus 23:6). Commenting on this theme, David Clyde Jones has noted that justice “must always be on its guard to preserve and protect the rights of the socially weak, specifically the poor, aliens, orphans, and widows” (85). All of these socially weak groups are in positions where their vulnerability makes them candidates for exploitation, a situation analogous to that of a patient or research participant.
The justice that God expects is closely related to the sanctity of human life. Each human is worthy of respect because man is created in the image of God and because God has placed innocent human life in a special category of protection. In fact, these two principles intersect in Genesis 9:6, where the condemnation of murder is related to God’s image in man. Combining the doctrine of the imago Dei and the principle of the sanctity of human life reveals that the integrity of each patient or research participant should be honored. When applied to civil autonomy, this means that individuals should not be impaired in their decision-making by threats to their lives, threats to the lives of their family members, or threats to their freedom to accept or reject treatment. Millard J. Erickson reflects my intended concept when he says, “Because all are in the image of God, nothing should be done which would encroach upon another’s legitimate exercise of dominion. Freedom must not be taken from a human who has not forfeited this right by abusing it” (517).
Having established that freedom from coercion or unwanted medical experimentation is fundamental to civil autonomy, how do we evaluate issues of diminished capacity? The effects of the fall move beyond the spiritual and mental aspects of humanity and affect the body as well. Death means that the human body degenerates to the point that it ceases to function. As the body degenerates from the result of old age, disease, or accidents, people progressively lose more control over their own capacity to choose. The effects of sin make it clear that, biblically speaking, all people suffer from diminished capacity to some degree. While all people should be respected as having the potential for full capacity, the reality is that everyone is limited in some way concerning the decisions he or she makes. As such, a biblical approach to civil autonomy grounds the right of every person to be free from harmful and unwanted procedures within a theological paradigm that acknowledges their right to choose but also acknowledges that these abilities are limited by the Fall. Christians can contribute in a very constructive way to policy development by asserting the biblical mandate to protect those who are weakest and most defenseless. Also, the Christian doctrine of sin informs our approach to policy development because we acknowledge that fallen humans have the capacity to coerce others.
Libertarian Autonomy
Libertarian autonomy refers to freedom from any constraining norms of behavior. The lack of transcendent moral accountability distinguishes libertarian autonomy from partial moral autonomy. This category might be described as a radical autonomy which focuses merely on an intensely personal and private standard of evaluation. Libertarian autonomy is also distinguished from civil autonomy. While civil autonomy focuses on freedom from coercion, libertarian autonomy goes further, demanding the right to choose any course of action apart from any ethical restraint. Such a position can be described as a human self-reliance at odds with a proper dependence upon, and obedience to, God.6 It is this form of radical autonomy that Colleen E. Clements and Roger Sider were critiquing when they said, “Somewhere along the way to autonomy ethics, medical norms have been forgotten” (2013). I contend that when evangelicals attack the principle of “autonomy” as inconsistent with Scripture, they are actually attacking this form of autonomy.
Derek Humphry is a good example of an advocate of this extreme form of autonomy. A strident proponent of the Death with Dignity Act in Oregon, Humphry played a key role in the expansion of patient autonomy beyond the confines of partial moral autonomy to libertarian autonomy. The founder of the pro-euthanasia Hemlock Society, Humphry gained notoriety for publishing an account of how he helped his first wife, Jean, kill herself. He has gone on to publish many other books relating to suicide. A tireless worker for legalization of suicide, Humphry summarized his position in 1986 when he said, “Patients should be given the option of terminating life or even given the option of having someone terminate for them when the situation is obviously quite hopeless. This need not necessarily be radical treatment of pain, but sometimes the terrible psychological situation that some dying patients find themselves in” (Humphry 307). Humphry opposes the traditional rejection of medicalized killing. Instead, he advocates a form of medical ethics based on a radically individualistic approach that I call libertarian autonomy.
Calls for radical approaches to autonomy are not limited to “right-to-die” groups alone. In 1988 the Journal of the American Medical Association (JAMA) published an article titled “It’s Over, Debbie.” The anonymous author claimed to be a gynecology medical resident at a large private hospital. During the night, a nurse informed this physician that a patient was having difficulty getting rest and needed attention. As the medical resident grabbed the patient’s chart and rushed to the room, the nurse gave hurried details. The patient was a twenty-year-old woman named Debbie who was dying of ovarian cancer. The author stated, “She was having unrelenting vomiting, apparently as the result of an alcohol drip administered for sedation. Hummmm, I thought, very sad.” (272). Upon entering the room, the resident reported that the young woman looked much older than twenty years of age. She had not responded to chemotherapy and was being given supportive care only. The resident described the encounter as follows: “It was a gallows scene, and cruel mockery of her youth and unfulfilled potential. Her only words to me were, ‘Let’s get this over with.’” Interpreting Debbie’s statement as a request for death, the resident administered a lethal dose of morphine sulfate. Within a few moments the patient’s labored respiration calmed to normal and within four minutes her “breathing rate slowed even more, then became irregular, then ceased” (272). The young doctor concluded by saying, “It’s over, Debbie.”
“It’s Over, Debbie” generated intense debate. The legal authorities in Chicago, where JAMA is headquartered, even initiated a criminal investigation. This investigation did not proceed very far because the JAMA appealed to a state law which protects journalists from revealing their sources. Willard Gaylin, Leon Kass, Edmund Pellegrino, and Mark Siegler published a response to “It’s Over, Debbie” in the JAMA and emphasized the lack of professional etiquette by the anonymous physician: “The physician behaved altogether in a scandalously unprofessional and unethical manner…. This is, by his own account, an impulsive yet cold technician, arrogantly masquerading as a knight of compassion and humanity” (Gaylin, et al. 2139). While it is not my purpose here to respond to specific euthanasia practices, the examples just cited do highlight what is at stake when libertarian autonomy serves as a guiding moral principle. Both Humphry and the anonymous author of “Debbie” acted beyond the restraints of traditional norms of medical ethics.
Libertarian autonomy assumes humans are sufficient in and of themselves to determine right from wrong. In fact, right and wrong as categories become quite indistinct, and ethics becomes merely a matter of subjective opinion. As such, libertarian autonomy rejects any reference to theism in decision-making. Julian Savulescu reflects just such a hostile approach to integrating religion and medical ethics. He argues that adherence to transcendent principles of morality leads religiously motivated patients to consume scarce resources during the last phases of life: “While some religious fundamentalists consume scarce community resources waiting for miracles, receiving futile treatment, other people are dying or being denied scarce effective medical treatment” (383). Instead of respecting ethical opinions based on transcendent moral accountability, he argues, “If anything, there is less reason to respect religious requests that are based on irrational beliefs” (383). Finally, in an apparent stab at Christianity, he states that religiously motivated people should not really worry about end of life decisions: “God has supposedly raised people from the dead so death should be no obstacle to a miracle occurring” (383).
In contrast to Savulsecu’s stinging criticisms, the Christian worldview affirms at a most basic level that man is contingent: Humanity exists because of God’s creative act and continues to exist because of His providence. The biblical position is that there is a strict distinction between the creature and the Creator. Though mankind is the pinnacle of creation, this lofty position is not to be transmuted into a worship of man, a main emphasis of the first and second commandments. As Thomas Oden says, “Autonomous Individualism makes an idol of the detached individual as a self-sufficient, sovereign self”(118). Paul criticized the worship of creation when he said that fallen man “worshiped and served created things rather than the Creator—who is forever praised” (Romans 1:25b). Paul went on to stress that violence and intergenerational conflict are the results of anthropocentric ethics (Romans 1:28-32). As dependent creatures, we do not have life from ourselves, a concept emphasized in 1 Timothy 6:13, in which Paul wrote, God “gives life to everything.” Charles P. Arand captures this emphasis on man’s contingency when he says, “Theologically, we cannot speak of a person as a truly autonomous, self-sufficient, and independent being…. Any talk of independence must take place within the context of our dependence upon God and upon those through whom God works” (394). Because man is dependent, the Christian position rejects an approach to medical ethics where an individual establishes his or her own norms without any regard to revealed standards.
Libertarian autonomy also grossly neglects harmiatology. The Bible affirms repeatedly that humanity can only be understood as contingent and fallen. Karl Barth summarizes the Christian position and the corresponding dangers of rejecting it. He points out that humans are autonomous in the sense that the individual is “not an extension of God or a part of God” (178). However, Barth goes on to stress the contingent nature of the autonomy: “Naturally, the individuality and autonomy are only of such a kind as His own goodness can concede and grant. God could not be God if he willed and permitted any other individuality or autonomy side by side with his own. An independent autonomy or individuality could be only devilish in character” (178). Barth’s remark that an independent autonomy “could only be devilish in character” should be especially noted. The heart of the original temptation, “You will be like God” (Genesis 3:5), is an invitation to an unrestrained, libertarian autonomy.
While the New Testament does speak of “freedom,” the concept is dissociated from the idea of freedom as the power to do with one’s life whatever one wants. For example, James 1:25 and 2:12 refer to the “law that gives freedom.” However, this is not meant to imply absence of moral constraint. In fact, the biblical position is that a self-centered libertarian autonomy actually leads to a kind of bondage in which people become slaves to sin (John 8:34). Thus, the thrust of Paul’s argument in Galatians that we are free from the law (5:1) does not mean he is advocating an antinomian position. On the contrary, we are released from a self-centered sphere of activity and are now free to do the will of God. The conclusion becomes clear: an evangelical analysis of libertarian autonomy reveals that this approach is fundamentally at odds with biblical and Christian ethics.
Libertarian Autonomy and Current Trends
I contend that this last form of autonomy, libertarian autonomy, is at the core of several significant court decisions relating to medical ethics and the health sciences and that it is the central component in the approach taken by leading ethicists. While choosing key dates for shifts in thinking can be somewhat arbitrary, I believe this trend in legal thought can be traced to Griswold v. Connecticut (1965). This case revolved around a Connecticut law that prohibited the use of contraceptive devices and the giving of medical advice on their use. In a 7-2 decision, the Supreme Court of the United States declared the law unconstitutional. This case is significant because it is the first case in which the Supreme Court declared a constitutional right to privacy. Writing for the majority, Justice Douglas said the Connecticut law violated the “zone of privacy” created by several fundamental constitutional guarantees. Soon thereafter, Roy Lucas suggested this ruling could have implications for abortion laws in his seminal 1968 article “Federal Constitutional Limitations on the Enforcement and Administration of State Abortion Statutes.” Arguing for liberalization of abortion laws, Lucas said, “The values implicit in the Bill of Rights suggest that the decision to bear or not bear a child is a fundamental individual right not subject to legislative abridgement—particularly in light of Griswold v. Connecticut" (Lucas 761).
Griswold in fact was a significant legal precedent cited by the Supreme Court in the Roe v. Wade case of 1973. While the implications of Roe for abortion on demand are well documented elsewhere, I want to focus on the fact that the Roe court widened a “right to privacy” from one area, contraception, to a closely related area, pre-born human life. However, while the court used the language of “privacy,” it was in reality dealing with issues of autonomy. In his historical review of abortion in the Roe case, Blackmun appealed to pagan practices in Greece and Rome which devalued newborn life and said, “Greek and Roman law afforded little protection to the unborn” (Roe 131). Yet even if the pre-Christian pagan culture did affirm abortion, does that in and of itself give warrant for devaluing pre-born human life? Paganism accepted other violent practices that most people find repulsive. Blackmun made no moral evaluation of the pagan morality but treated it in a morally neutral matter. In the process, he reverts to the violent morality of ancient Rome (the unborn are afforded little if any protection), leaping over the entire Judeo-Christian legal heritage and returning to a pre-Christian pagan approach. Thus, at the heart of the Roe decision is a question of worldviews: Blackmun advocates a worldview in which the weakest are not protected and might makes right. Paganism itself, as Paul makes clear in Romans 1:18-32, eventually breaks down into libertarian autonomy. Why? Paganism is polyvalent and not constrained by a revealed standard. Thus, paganism is closely related to idolatry, creating a god and a belief system that conforms to our own tastes.
The radical notion of autonomy central to the logic of Roe is clearly seen when one understands the implications of the companion decision delivered the same day in 1973, Doe v. Bolton. While Roe says that states may regulate abortions in the third tri-mester except where the health of the mother is concerned, Doe defines maternal health in the broadest possible context to include not only physical health but psychological and familial factors as well. In his recent work on bioethics, Edwin C. Hui says the Supreme Court in Roe declared that abortion was “not an absolute right and must be subject to limitations imposed by the state’s interest to protect maternal health, uphold medical standards and protect prenatal life at some crucial point of fetal development” (Hui 298). What Hui misses is that Roe and Doe must be examined together and taken as a whole: the latter clarifies and expands the former.
This brings us back to the case I mentioned at the beginning of this article, Planned Parenthood v. Casey. Again, in that case which reaffirmed the core finding of Roe, the Supreme Court said, “These matters involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment.” I believe the Casey court has stated more clearly than the Roe court what is at stake: autonomy. Yet, I also concur with Edward J. Larsen and Darrel W. Amundsen’s critique of the Casey court when they say, “The justices obviously wrote this with abortion in mind, but by trying to state a general principle, they created a limitless category” (211). In fact, the Ninth Circuit Court used the Casey decision as a precedent when it over-ruled a ban on physician-assisted suicide in Washington in Compassion in Dying v. Washington (1996).
On June 26, 1997, the Supreme Court reversed the Ninth Circuit Court in a decision now known as Washington v. Glucksburg. Of significant interest is that a distinguished group of philosophers and ethicists filed a friend of the court brief, urging the Supreme Court to affirm a Constitutional right to physician-assisted suicide. Titled “Assisted Suicide: The Philosopher’s Brief,” the contributors included John Rawls, Judith Jarvis Thomson, Robert Nozick, Ronold Dworkin, T.M. Scanlon, and Thomas Nagel. Central to their argument was a notion of unrestrained autonomy. These same philosophers also appealed to the statement on autonomy from the Casey decision that I quoted earlier. They state, “In a free society, individuals must be allowed to make those decisions [life, death, etc.] for themselves, out of their own faith, conscience, and convictions” (Rawls, et al. 7). The philosophers go on to insist that Casey compels one to affirm the legality of physician-assisted suicide.
This is the form of radical autonomy that evangelicals reject. Writing during a more conservative era in his career, Clark Pinnock critiqued just this form of libertarian autonomy: “The person authenticates himself by a bare act of the will. Autonomy in ethics leads directly to arbitrariness in ethics” (48). However, in the rush to critique such extreme concepts, some very vital important concepts are often overlooked. Partial moral autonomy protects the freedom of people to set their own course for life within limits. Civil autonomy protects people from violence and coercion. Both of these principles are consistent with Scripture. Clarity on what forms of autonomy we accept and reject can facilitate healthier debate and clearer guidelines for research and institutional protocols. Notions of libertarian autonomy are inconsistent with transcendent moral accountability because they neglect human contingency and ignore divine accountability.
When autonomy is exercised in its most libertarian form, medical ethics quickly breaks down into a question of procedure rather than a matter of moral absolutes. While I have focused primarily on autonomy concerning patients and research subjects, the nature of medicine and research presents numerous opportunities for the abuse of power if physicians adopt libertarian autonomy. Closely connected to this abuse of power is the marginalization of the weakest members of society. Thus, libertarian autonomy actually serves to facilitate coercion against the defenseless, the very antithesis of autonomy itself. This presents a striking bit of irony. The philosophical principle, autonomy, which came to the forefront in the second half of the twentieth century in order to secure certain freedoms for patients, can be taken to such a libertarian extreme that the civil autonomy of patients is actually diminished.
Addendum
Shortly after this article was completed, the Supreme Court issued its Lawrence v. Texas decision on June 26, 2003. In this case, the court voided a Texas law prohibiting homosexual intercourse. In so doing, the Court reversed a 1986 ruling, Bowers v. Hardwick, in which the Court had said that laws prohibiting such behavior are Constitutional. What motivates the Court to make such a decided shift in direction a mere seventeen years later? In the opening paragraph, Justice Kennedy gives us the court’s rationale when he says, “Liberty presumes an autonomy of self that includes freedom of thought, belief, expression, and certain intimate conduct.” Thus, the court has again expanded the activities protected under the concept of “autonomy.” The radical version of autonomy that the majority advocates in Lawrence is intensely individualistic without reference to transcendent standards of moral accountability for they also say, “As the Constitution endures, persons in every generation can invoke its principles in their own search for greater freedom.”
The Court states in Lawrence, “When sexuality finds overt expression in intimate conduct with another person, the conduct can be but one element in a personal bond that is more enduring. The liberty protected by the Constitution allows homosexual persons the right to make this choice.” The Court seems to make the assumption that every sexual encounter is part of an “enduring” personal bond. This is moral nonsense. Outside the confines of heterosexual-monogamous marriage, sex leads to promiscuity as well as the exploitation of others. Furthermore, though the Court claims these matters cannot be addressed by the government, the Court itself is indeed taking sides in a moral debate! The court claims to be neutral, but is really advocating an autonomy-driven sexual libertinism. As others have stated, a state that treats all alternative lifestyles as equal does not have producing good citizens as a goal, but rather merely permits each autonomous individual to decide for himself or herself what is good, true or beautiful. Such an approach is not good civics, but is instead merely “nihilism with a happy face.”
Notes
1 The court allowed a form of parental consent to continue as long as certain regulations are followed. The court also upheld a mandated twenty-four hour waiting period prior to an abortion.
2 I recognize that the use of the term autonomy in reference to the U.S. Constitution is slightly anachronistic since the word was not used in English regarding individual morality until after 1800.
3 Millard J. Erickson argues that theological interpretations of the imago Dei can be divided into the substantive view, the relational view, and the functional view (517-36). Of these three, I affirm that the substantive view is the foundational and the grid through which other aspects of the imago should be seen. In contrast, Edwin C. Hui argues that the relational view as popularized by Karl Barth should be our starting point (143-48).
4 All biblical quotations in this article are taken from the NIV translation.
5 This is Verhey’s opinion. See “The Person as Moral Agent,” 5.
6 This terminology is based on statements from A New Dictionary of Christian Theology, s.v. “Freedom,” by A. O. Dyson, 60.
Works Cited
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Barth, Karl. Church Dogmatics. Vol. II.2. Eds. G. W. Bromiley and T. F. Torrance. Edinburgh: T&T Clark, 1957.
Beauchamp, Tom, and James Childress. Principles of Biomedical Ethics. 4th ed. Oxford UP, 1994.
Beckwith, Francis. “Absolute Autonomy and Physician Assisted Suicide.” Suicide: A Christian Response: Crucial Considerations for Choosing Life. Eds. Timothy J. Demy and Gary P. Stewart. Grand Rapids: Kregel, 1998. 223-233.
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Dyson, A. O. “Freedom.” A New Dictionary of Christian Theology. Eds. Alan Richardson and John Bowden. London: S.C.M. Press, 1983. 60-61.
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Murray, Thomas. “Communities Need More Than Autonomy.” The Hastings Center Report 24.3 (May-June 1994): 32-33.
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President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Washington: GPO, 1982.
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J. ALAN BRANCH <ABranch@mbts.edu> is Vice President for Student Development and Appointed Assistant Professor of Christian Ethics at Midwestern Baptist Theological Seminary, in Kansas City, Missouri. He earned a B.B.A. from Kennesaw State College, an M.Div. and a Ph.D. from Southeastern Baptist Theological Seminary. His area of specialty is medical ethics.
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