Abstract
This thesis is about what it means to support a person’s autonomy. The concept of autonomy, or self-governance, is central to Western medical ethics and is widely considered to underly a person’s right to consent to or refuse medical treatments and clinicians’ corresponding obligation to facilitate people making their own informed decisions. However, people with certain cognitive impairments are widely considered incapable of autonomous decision-making. Instead, medical decisions are made for these people by substitute decision-makers. In 2006, the United Nations adopted the Convention on the Rights of Persons with Disabilities (CRPD). The CRPD has been interpreted as challenging current medical practice by calling for substitute decision-making to be replaced by supported decision-making. Supported decision-making aims to respect a person’s autonomy by assisting them in making their own decisions instead of having a substitute make decisions for them. Whilst there has been much debate about how the CRPD’s requirements should be interpreted and implemented, little research has explored how individual autonomy should be understood in supported decision-making. This thesis develops a theory of dependent autonomy to understand what it means for a person to be supported to be autonomous. The most influential understanding of autonomy in medical ethics—that of Tom Beauchamp and James Childress—requires a high degree of independence and self-sufficiency for actions to be considered autonomous. Following theories of autonomy from the broader philosophical literature, I discuss how autonomy can be understood as a person deciding or acting on motivations that represent their authentic self—those characteristics that comprise the core of their identity. I argue that full independence is unnecessary for exercising autonomy when understood in this way and that others can assist a person in translating their autonomous motivations into action, thus essentially outsourcing their agency into the surrounding environment. This raises the question of how autonomous motivations should be understood. Harry Frankfurt and Gerald Dworkin have influentially argued that a person is autonomous when they are motivated by a desire they want to have. Contrary to this, I argue that a person’s values better represent their authentic self than their higher-order desires. Drawing on a theory of the self from Charles Taylor, I argue that a person’s values comprise the core of their identity when they are mutually coherent. I conclude that understanding supported decision-making as helping a person translate their coherent values into action provides not only a theoretical basis but also a strong justification for the practice.