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More autonomy -
new responsibilities?
The concept of personal autonomy
in the reproductive issues | Bogdan Olaru
| Abstract
Arguments based on autonomy are thought to be strong in the fields of human reproduction. Despite the agreement about the respect that we should pay to the personal autonomy, the real difficulties show up when we deal with the variety of meanings that are assigned to this basic principle. I will illustrate these difficulties by showing how misleading it can be to plead for new forms of personal autonomy and focus exclusively on principles without paying the necessary attention to the emphasis they receive in different contexts of the social life (1). I will argue that the presumptive correlation between new autonomies and new responsibilities do not always make sense (2). This is more obvious especially when prescribing such new genuine responsibilities in the respect for human nature (3). I find more profitable to see genetic and reproductive technologies at the crossing point between private and public sphere and to understand that the autonomy claims experiment with different restraints, therefore we cannot expect to get a unifying view about how far these claims should go (4).
Key words: autonomy, responsibility.
1. New forms of personal autonomy?
The highly developed medical technologies of the last few decades allow a higher access to the private sphere. The growing perspectives on birth control offer us a classic example. The assisted reproductive technologies, the human organ transplantations, the perspectives of prolonging the human life as well as the opposite tendency of controlling the biological life limits by euthanasia ? all these techniques imply medical interventions, through we are able to control and decide what to do with the biological resources of our life. One can call them new forms of extended personal autonomy. Apart from common sense, the medical intervention is more and more understood as medical service that one can buy and pay for.
(Of course, this is not the only way we can conceive the doctor-patient relationship.) On the other hand, the high scanning degree of the genetic information raises the question and the fear of new methods for controlling individuals and for limiting the human liberties. Some authors reveal these fears through concepts like "genetification" of the medicine or "biologization" of social life, concepts that are meant to express the tendency of controlling and designing the "life-world" by accessing its biological basis.
I will discuss some recent cases that illustrate how this tendency spread out over the Romanian society. There are some hospitals in Romania that have the technical capacity for offering services of assisted reproduction. At the beginning of 2005, the Romanian society has shown a great sensibility for the case of the Romanian mother who gave birth at 66 years-old and proved also a high interest in how the assisted reproductive technologies are used and regulated. The public debate that has taken place about this case has pointed out the psychological and social risks that are susceptible to come out when the use of these techniques is insufficiently regulated. It has been asked, for example, whether and how the assisted reproductive technologies may affect parent-child relationships. The consequences of the massive intervention of advanced technologies in our life can be investigated by surveying the process of socialization of the children that are born by using assisted reproductive technologies and may provide an object for future research.
Another step that can follow, due to the current lack of legislation and reduced experience on counselling matters that seems to be a serious problem in Romania, is to associate reproductive technologies with the genetic scanning techniques and open the way for PGD-procedures. This step would raise ethical concern about the inequities that could appear in our society as well as about whether and how we interfere with the biological existence of future generations.
Another recent example provided by the Romanian reality which has highlighted our social vulnerability and the insufficient surveillance of the medical services is represented by the Global Art Company, specialized in commercializing medical services like in vitro fertilization. The lack of legislation that must regulate the medical services of assisted reproduction (the donation of ovules, more precisely) made possible to take advantage of the naivety and the precarious material status of the Romanian female donors who have thus exposed themselves to serious health risks. We must defend the right to choose of the donors, but it must be asked if they were actually able to take autonomous decisions as long as they experienced poverty and had to face significant social pressure.
Such experiences produce massive negative reactions towards medical technologies, especially towards assisted reproductive technologies (the press reports have widely used suggestive terms expressing disapproval or criticism like "children mail delivery").
2. Exploring further responsibilities
Such new experiences challenge our society with new tasks. We are living in a social background where individualization is rising and the medical practice offers new methods for controlling and designing our lives. All these give us serious reasons to analyse the potential of human medicine techniques. New forms of responsibilities and normative measures must compensate new prospective ways of control and new potential individual options that are likely to increase in the next few decades.
Facing the tendency of commercialisation of the medical services, we must forewarn that a high risk for human life and dignity is becoming real by assigning to medical services expectations and aims that no longer share a curative meaning. One difficult point is to deal with the justified claims for free choice in a context where the patient has come to a greater extent a "client" for the medical services. Autonomy seems to be a central value for modern society and plays a key role in reproductive matters too. A simple moral intuition says that one cannot dispose over his body in all the ways he or she wants. To give too much weight to personal autonomy may be misleading.
We can see now that the disapproving attitude of the Romanian society towards the sexagenarian mother was rather a reaction against the general tendency of conceiving personal autonomy as self-determination, independency and making of it the single central point that counts. Firstly, there are responsibilities that the simple appeal to self-determination seems to involve and one of these is the responsibility for preserving a state that we positively value as a good one, as long as it maintains its stabile configuration. Secondly, there are responsibilities for the consequences of our actions. It may sound trivial, but the only actions that are susceptible to be evaluated from an ethical point of view are those of self-determined actors. Thirdly, when the consequences of our actions may affect the future generations (such as the techniques of the birth control through the genetic scanning), we must learn to deal with new forms of responsibilities orientated towards the future.
I would like to outline some difficulties related to this kind of responsibilities. Approaches of social research field suggest an appropriate perspective on this subject. Thomas Lemke [1] has shown that in the societies where the genetic investigations are current practices, these measures are on the way to generate a so-called "genetic responsibility".
This new kind of responsibility is manifested by a higher consciousness of individuals for their life-style. They become more sensitive to a rational and healthier behaviour and for a life-style that is more adequate to the genetic predisposition for some serious diseases etc.
But we can see also increase the responsibility of our society for health problems. Identifying the causes of the diseases and the potential health risks means to generate new responsibilities and nominate the actors that are able to assume these responsibilities. An advanced understanding of the causes of the diseases and of the resources of the medical technologies could lead us to a more accurate perception of the strategies that are required for the management of the health problems.
This result is correct and it seems beyond doubt that the variety of the predictable consequences as well as the range of the unintended consequences is increasing with the spread of technological innovations. If the things that must be done will be new and the consequences that are to be expected just as well, it is reasonable to question if we actually deal or will deal with new and genuine kind of responsibilities, or if we rather will discover and experience new ways of becoming aware of the common and daily responsibilities that we should share with all the others.
3. There is nothing normative beyond the moral frames
A reason why it is difficult to describe these new genuine responsibilities is because it is quite controversial to identify the actors (individuals or institutions) that must assume these responsibilities. If one wants to set normative obligations from an ethical point of view, one must provide a clear answer to the question whether these obligations are actually assignable to anyone. This seems to be a problem for many of the theoretical approaches that are dealing with the biotechnical intrusions in human life from a normative point of view.
One of these theories sets a high value on the so called "the nature of human beings".
The respect for the nature of the human being, argues Wolfgang van den Daele, should function as a background principle for the regulation of the biotechnological intrusions in human life. [2] To set limits for technical interventions in everyday life means to guarantee a space where life is protected against instrumentalisation. The basis on which the normative process can be provided is only by assuring this inviolable level of life. We must not overlook that an adequate understanding of nature may not include references to normative or teleological principles such as religious insights about creation and sanctity of life.
If we include such insights, than human nature reveals itself as a construction, therefore open for reconstruction. Linking the genetic screening and genetic techniques to the research of our nature as biological species may let us think that human nature itself is becoming more and more a construction by means of these investigatory techniques. [3] The criteria to define human nature are always open to revision in the light of the potential technical progress. [4] Human nature is no more a solid, stable and definitely determined essence. A certain amount of incertitude may no more be avoided. From now on, we must accept that human nature includes the possibility of self-alteration, due to the prospective genetic technology. But it is a part of the renewed understanding of human nature to see it as open for technical reassessments and conceive it not only as an object for evolution, but also as a subject that takes part in this evolution. This is a consequence that may be read out of the description of human beings as deficient, indeterminate creatures (Mangelwesen), a thought that Helmut Plessner und Arnold Gehlen (amongst others) have elaborated. The re-established appeal to human nature should draw limits on the technical interventions in daily life. But Van den Daele fails to show what the normative function of his concept of "naturalness" consists in, supposing that human nature is potentially open to any kind of transformation via genetic modification. He argues that if we act in accordance with the naturalness of human nature, we will be discharged from the anxiety of misleading experiments. Individuals will generally act all the same while maintaining natural coordinates. Human nature itself will become a self-regulating factor. This is no reasonable guarantee. [5]
Now it is obvious that no one may require from others to act in accordance with a so-called "naturalness" of the human being and make of it the origin for a genuine responsibility. Somebody can speak about the respect for the human nature as for nature generally but is there an obligation to remain within any natural bounds? That is why no special responsibility for human nature itself and no normative limits are here to be found. Jurgen Habermas has stressed that any attempt to set normative functions to what ever could be this ?naturalness' of the human being, would led back to a position that assumes religious or mythical views. It will be better if we do not ?moralise' human nature. [6] Yet, we can ask to preserve the social configured frames, as his theoretical approach demands. This requirement rises from the fact that moral assumptions function only as long as they are embedded in a social life. Liberal eugenics comes with the prospective view of reshaping all of humankind, affecting the structures of the social frameworks too. The genetic engineering and the ART-techniques ask about the eugenic enhancement of the future generations. We may want to manipulate the genetic identity of our children, from the point of view of what we do now believe that may be desirable (healthy, good, beautiful etc.). This "optimisation", argue Habermas, will endanger the socialisation processes because it will establish an irreconcilable asymmetry between the actual and the future generations. The socialisation processes take place only if the possibility for agreement, as well as for critical disagreement, remains open. That is the way the things are going on by learning, where children may reconsider, change or modify the parents' or teachers' decisions.
If children have not been allowed to revise the decision that their parents have made for them (as it may be the case for genetic optimisation), socialisation were compromised. [7] Our understanding as moral beings could no longer be possible. [8] Hence, the claim for autonomy would make no sense any more.
Habermas calls for a clear vision about our future as a human race from an ethical point of view (ein gattungsethisches Selbstverstandniss). The question is: "What do we want to do with us as human race?" Or, as Habermas says: "Do we generally want to understand ourselves as normative beings at all?". [9] But there is no moral obligation to act morally. These considerations cannot lead to any kind of moral responsibility, even less to the responsibility for preserving the essential reciprocity of the socialisation processes, precisely because the moral itself functions inside these social frameworks. And there is no entity that could request for us to remain inside these frames.
4. Autonomy in the debate over the private and the public sphere
I will discuss what has become ob-vious up till now. We are living in a cultural context where the arguments based on autonomy claims are strong arguments. The freedom of choice manifests itself in ways that affect us both as biological creatures and as social actors. These are, for instance, decisions that are taken in reproductive matters and about end-life situations. The more the need for freedom and autonomy is growing, the more it becomes necessary to regulate the space of action they claim. Yet, neither a biological, nor a social theory can provide us with normative principles for limiting the technical intervention in the human life. Then, how do we deal with the autonomy claim and how do we understand if and where this claim generates new responsibilities? And how it is possible to limit the potential harm that the biotechnologies could cause, without producing an infringement of the basic right to autonomy? Is autonomy the thing that makes us praise humanity and human beings?
First of all, we must notice that the common approaches to the autonomy are quite various and depend on the field where they are intended to solve problems. One thing is to argue for reproductive autonomy and another is to discuss the difficult problems of free choice over life-end.
And quite another is to prospect the different claims for self-designing and drug consuming. This makes us think about several theoretical models, in which the arguments based on autonomy merge with other context-related arguments. For example, stopping the treatment of a patient in a terminal stage means that the assisted suicide is morally permissible. The request of the patient can never be seen as a sufficient condition for no one who wants to argue for voluntary euthanasia. Other factors like pain, suffering and personal views about what a life worth living means should be taken into account.
[10] The reproductive techniques merge on the other hand two sets of questions, related to the freedom of reproduction of the individuals and to the medical and social safety of the child (as well as of the parents themselves). There are also other fears about possible social inequities that a more liberal eugenics could generate. The point is to attain a balance in all these aspects, but the autonomy claims experimenting different restraints, depending on the life area where they emerge.
The autonomy claims different discursive contexts and this is a reason why we cannot expect to get a unifying view about how far this claim should go. Consequently, we cannot get a clear perspective about when a violation of the right to autonomy is actually a real one. This may encourage the view that the autonomy belongs to a private discourse that opposes a public one and that the two kinds of discourses are incommensurable, as some authors think to be the case when they oppose the vocabulary of self-creation and private perfection to the vocabulary of justice and human solidarity. [11]
Yet, the two kinds of discursive contexts interfere very well and it is often of great interest, but not only from the practitioner point of view, to interlink and mediate the two "vocabularies". The act of assisted suicide and the reproductive medicine are the most notably examples that make us aware of how vital is to construct arguments that make sense in both private and public sphere. We want to have a permanent access to both levels and not just navigate from one to another. Onora O'Neill has made this point when she states that the increasing attention paid to autonomy must face decreasing public trust: "Do we have to choose between respect for individual autonomy and relations of trust? None of these prospects would be particularly welcome: we prize both autonomy and trust. But can we have both?" [12]
And indeed, the thing that really matters is to have them both. The real challenge is to find a way to build trust whereas we continue to protect the autonomy, how to assure the conditions for justice without producing an infringement of the autonomous choice.
References
[1] Veranlagung und Verantwortung. Genetische Diagnostik zwischen Selbstbestimmung und Schicksal, Bielefeld, 2004;
[2] Van den Daele W., Mensch nach Ma?. Ethische Probleme der Genmanipulation und Gentherapie, Munchen: Beck, 1985. S. also: Die Naturlichkeit des Menschen als Kriterium und Schranke technischer Eingriffe, in: WechselWirkung 103/104 (Juni/August), 2000;
[3] Losch A., Genomprojekt und Moderne: soziologische Analysen des bioethischen Diskurses, Frankfurt/Main, Campus-Verlag, p. 66, 2001;
[4] Van den Daele W., op. cit., p. 206, 1985;
[5] ?Individuelle Entscheidungen aber werden keine massenhafte Abkehr von der Naturlichkeit des Menschen herbeifuhren. Wie sich am Beispiel der kunstlichen Befruchtung ablesen lasst: Die meisten Menschen lassen tatsachlich die meiste Zeit alles so, wie es immer war", WechselWirkung 103/104, Juni/ August, 2000;
[6] Habermas J., Die Zukunft der menschlichen Natur, Suhrkamp, p. 46, 2001;
[7] ?Die interaktive Struktur von Bildungsprozessen, in denen das Kind stets die Rolle einer zweiten Person einnimmt, macht die charakterformierenden Erwartungen der Eltern grundsatzlich ?anfechtbar? ? [die Kinder] konnen die Asymmetrie der kindlichen Abhangigkeit retrospektiv ausgleichen und sich auf dem Wege einer kritischen Aufarbeitung der Genese von freiheitseinschrankenden Sozialisationsvorgangen befreien. ? Eben diese Chance besteht nicht im Falle einer Fixierung, die die Eltern nach eigenen Praferenzen vorgenommen haben. Eine genetische Intervention eroffnet nicht den kommunikativen Spielraum, das geplante Kind als eine zweite Person anzusprechen und in einen Verstandigungsprozess einzubeziehen. ... Die hadernde Auseinandersetzung mit der genetisch fixierten Absicht einer dritten Person ist ohne Ausweg." ? Habermas J., op. cit., pp. 107-108, 2001;
[8] ?Aus dieser Perspektive drangt sich die Frage auf, ob die Technisierung der Menschennatur das gattungsethische Selbstverstandnis in der Weise verandert, dass wir uns nicht langer als ethisch freie und moralisch gleiche, an Normen und Grunden orientierte Lebewesen verstehen konnen." ? Habermas J., op. cit., p. 74, 2001;
[9] Habermas J., op. cit., p. 32, 2001;
[10] See, for example, Dworkin G. (ed.), Euthanasia and physician-assisted suicide, Cambridge University Press, 1998;
[11] Rorty R., Contingency, Irony and Solidarity, Cambridge University Press, 1989;
[12] O'Neill O., Autonomy and Trust in Bioethics, Cambridge University Press, p. 4, 2002.
Internet resources
www.now.org/issues/abortion/
academic.udayton.edu/Health/05bioethics/reproduce.htm
www.themodernreligion.com/misc/sex/s_repro.htm
usliberals.about.com/od/reproductiveissues/
www.endo-society.org/educationevents/ print/roundtable_brc.cfm
www.nationalmssociety.org/pdf/forpros/Pregnancy.pdf
www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/ pages/hc_reproductivesystem?
www.nyas.org/annals/detail.asp?annalID=769
www.sciencenetlinks.com/pdfs/ethics_assessment.pdf
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