When Self Determination Runs Amok

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I take it that it isn’t plagiarism if one identifies one’s source. In this case I have borrowed the title from an essay by the estimable Daniel Callahan from another journal, The Hastings Center Report.[1] In this essay, Callahan argues on several grounds against the legalization of physician-assisted suicide and euthanasia, not least on an unbridled and undisciplined notion of patient self-determination. Likewise, philosopher Carl Elliott has explored the limits of self-determination in his ground-breaking volume, Better Than Well: American Medicine Meets the American Dream.[2] Elliott interviews patients who self-describe as “amputee wannabes” or call themselves an “amputee-by-choice.” These are individuals who see their limbs as alien to their bodies and ask physicians to remove perfectly healthy limbs because of a perfectly unhealthy body dysmorphic disorder.

Although it is demonstrable historically that medicine has sometimes—or more properly, physicians have sometimes—been guilty of strong paternalism, adopting it’s polar opposite, absolute patient autonomy, seems too radical for the wellbeing of both patients and the treatment they sometimes desperately require. Yes, Hippocrates is credited with saying, “Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgement difficult.  The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals co-operate” (Aphorisms). And this can certainly be taken to entail strong paternalism. “Making” the patient, and everyone else, cooperate is quite a prescription.

Nevertheless, such a potent paternalism is not endemic to proper medical care and, as both Callahan and Elliott argue, neither is potent patient autonomy. I would argue that the physician’s covenant to use her training and gifts for the wellbeing of the patient should be accompanied not by a patient’s determination to do whatever her or she wants to do, but by a negotiated compliance with the physician’s recommendations with the acknowledgement that physicians are not right all the time, and neither are patients. In other words, just as the physician joins a covenant to heal, so the patient joins the covenant to comply and be healed.

Granted, there are extremes to be avoided and, granted, the patient’s body is the patient’s property, as it were. But medicine deserving of the name cannot be governed by naked self-determination. After all, the word “patient” comes from a root that means “sufferer.” The sufferer is compromised by dis-ease that he or she presumably cannot remedy. So the patient appeals to the physician who is pledged to aim for the good of the patient. The medical covenant is, therefore, more like a dance than a DIY project. In a dance the partners both have an important role to play. One leads and the other follows, but neither works independently of the other; neither partner is autonomous, and there are rules and patterns to follow.

Contemporary patient care is in desperate need of an ethic that avoids both the extremes of paternalism and autonomy. The patient is a person, as the late Paul

Ramsey put it, and so is the physician. The healing dance—or the treatment tango, if you will—requires partners who are willing to respect one another, negotiate their relationship, and take steps together that move the patient toward well-being. E&M


[1] Callahan, Daniel. The Hastings Center Report, March/April 1992, pp. 52-55.

[2] Elliot, Carl. Better Than Well: American Medicine Meets the American Dream, Norton, 2003.

Cite as: C. Ben Mitchell, “When Self Determination Runs Amok,” Ethics & Medicine: An International Journal of Bioethics 35, no. 3 (2019): 133–134.

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C. Ben Mitchell, PhD
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