Journal ofMedical Ethics 1999;25:522-527

Autonomy, liberalism and advance careplanningSharon Ikonomidis and Peter A Singer University of Toronto, Canada

AbstractThe justification for advance directives is grounded inthe notion that they extend patient autonomy intofuture states of incompetency through patientparticipation in decision making about end-of-lifecare. Four objections challenge the necessity andsufficiency of individual autonomy, perceived to be adefiningfeature of liberal philosophical theory, as abasis of advance care planning. These objections arethat the liberal concept of autonomy (i) implies amisconception of the individual self, (ii) entails thedenial of values of social justice, (iii) does notaccountforjustifiable acts ofpaternalism, and (iv)does not account for the importance ofpersonalrelationships in the advance care planning process.The last objection is especially pertinent in light ofrecent empirical research highlighting the importanceofpersonal relationships in advance care planning.

This article examines these four objections toautonomy, and the liberal theoreticalframework withwhich it is associated, in order to re-evaluate thephilosophical basis of advance care planning. Weargue that liberal autonomy (i) is not a misconceivedconcept as critics assume, (ii) does not entail thedenial of values of social justice, (iii) can accountforjustifiable acts ofpaternalism, though it (iv) is notthe best account of the value ofpersonal relationshipsthat arise in advance care planning. In conclusion,we suggest that liberalism is a necessary component ofa theoreticalframework for advance care planningbut that it needs to be supplemented with theories thatfocus explicitly on the significance ofpersonalrelationships.(_Journal ofMedical Ethics 1999;25:522-527)Keywords: Medical ethics; patient autonomy; liberalism;advance directives

A component of advance care planning, advancedirectives allow individuals to specify in advancethe type of medical interventions they want, anddo not want, to receive, and the person(s) theywant to make decisions on their behalf, if or whenthey become incapable of making treatment deci-sions themselves. To date, it has been assumedthat advance directives should be honoured since

they respect, or at least aim to respect, the value ofpatient autonomy.' Concern for autonomy stemsfrom "people's interest in making significant deci-sions about their lives for themselves and accord-ing to their own values or conception of a goodlife".2 By enabling a competent person to"extend" his or her autonomous decision-makingcapacity into a future state in which this capacityno longer exists,3 an advance directive presumablygives a person some control over the end of his orher life.4Although the liberal value of autonomy has thus

far been the philosophical basis of advance direc-tives, its necessity and sufficiency have recentlybeen challenged. Four objections suggest thatautonomy, perceived to be a defining feature ofliberal philosophical theory, is insufficient as abasis of advance care planning. These objectionsare that the liberal concept of autonomy(i) implies a misconception of the individual self,(ii) entails the denial of values of social justice,(iii) does not account for justifiable acts of pater-nalism, and (iv) does not account for theimportance of personal relationships in theprocess of advance care planning. The last objec-tion is especially pertinent in light of recentempirical research highlighting the importance ofpersonal relationships in advance care planning.56This article examines these four objections toautonomy, and the liberal theoretical frameworkwith which it is associated, in order to re-evaluatethe philosophical basis of advance care planning.

Objection I: liberal autonomy is a purelyindividualistic conceptThe first major objection to liberal autonomy isthat it implies a misconception of the self as arational, independent agent who is ultimately"unencumbered" or "disengaged"7 from all socialcontext and who is capable of making decisions inways that are essentially detached from otherhuman beings.8 An ethic of individual autonomy,critics claim, cannot serve as a basis for advancecare planning unless those engaged in theplanning process make treatment decisions in away that is removed from the interests of others.

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But patients do not make treatment decisionsstrictly on a self-regarding basis and are, rather,essentially attached to the lives of others, particu-larly those close to them such as family members.9The patient is too enmeshed in a network of rela-tions to others to be properly singled out as a self-sufficient decision maker.'0 Thus, autonomy can-not mean simply a person's right to choose forherself based on personal interests alone; others'interests are necessarily a factor in the process ofdecision making.

Similarly, communitarians have argued that aliberal conception of autonomy is deficient since itboth wrongly portrays the individual as essentiallydisconnected from the rest of the community andsince it demands the denial of the priority of com-munal values. The communitarian concept of theself is constituted by its ends-ends that are notchosen but rather are discovered by virtue of ourbeing embedded in some shared social context.Individual identity, and hence individual capacityfor choice, is not separate from but ratherstructured by these ends and the roles theindividual assumes with respect to thecommunity." The communitarian self is "narra-tive", ie, a self partly constituted by a life storywith a certain end, or telos, 12 which is"intersubjective".

Accordingly, the moral agent is not properlyviewed in an atomistic, dislocated way, as is asso-ciated with liberal theory, but rather is situated ina moral community from which moral identity,convictions, and judgments derive." The liberalautonomous self, perceived by communitarians asone able to stand apart from, question and reviseits convictions of the good life, is mistakenlydefined as prior to its ends and as having a virtu-ally unlimited capacity for choice.Contemporary liberalism, though, is not a

purely individualistic ethic. Liberal conceptions ofautonomy have always revealed an underlyinggeneral concept understood in terms of self-government, self-determination, or a kind of self-ownership of values, beliefs, desires, andchoices-in other words in terms of a life that isnot "other-governed". Yet, contemporary liberalinterpretations of autonomy are expressed interms of negative freedom, rank-ordered desires,personal identification, and, notably, historicalformation" which highlights the broad socialembeddedness of the individual.

This modern liberal concept of autonomy is anessentially historical notion in that the conditionsthat must be met in order for desires to beautonomous are properties of the formation of,and not mere identification with, those desires.'6What is crucial in the determination of whether a

desire is autonomous is the manner in which thedesire was formed, which may have little to dowith how the agent evaluates the desire itself.'7 Aperson is autonomous when he or she under-stands the development of and changes in his orher character. What modern liberalism thusstrives to preserve and promote in terms ofindividuals' autonomy is their ability to reflect onthe manner they develop as persons and on thesocial and cultural conditions that shape thatdevelopment through history.Though the liberal self has been described as

"atomistic" and "independent" in that "thefulcrum of the determination of autonomyremains the point ofview of the agent",'8 this doesnot mean that individuals are able to dislocatethemselves from their social and historical con-text. We are able to judge ourselves only in thelight of our social and cultural histories and themanner in which they affect and shape our devel-opment as persons. Modern liberals recognise thatit is impossible to think of ourselves except as partof ongoing communities, defined by reciprocalbonds of obligation, common traditions, andinstitutions. Liberal conceptions of autonomytherefore are not purely individualistic, as criticsclaim.

Liberals have always deplored the effects onindividuals of social manipulation, the conditionin which individuality is swallowed up by the col-lective mass.'9 The liberal concept of autonomyportrays the individual as a separate being with adistinct personal point of view and an interest inbeing able to pursue securely his or her own con-ception of the good, but it does not presume thatone is only accidentally and externally related toothers.20 Modern liberalism is not necessarilyobjectionably individualistic given that the liberalautonomous agent may be driven by choiceswhose origins are outside his or her control.Where such so called autonomous choices areexpressed, the interests of the individual may beoutweighed by the considerations of others, asdiscussed in the next section.

Objection II: liberal autonomy entails thedenial of social justiceThere exists a potential conflict between the prin-ciples of autonomy and justice where patientsappear to have the right to claim whateverresources they want regardless of the impact oftheir decisions on the welfare of others.2' To crit-ics who perceive liberal theory as a framework forthe exaggerated promotion of individual au-tonomy, it may not be clear how liberalism canaccount for advance care planning when the

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interests of society outweigh those of the indi-vidual. Practically speaking, all requests cannotand should not be honoured simply because theyrepresent the autonomous wishes of the indi-vidual.Although advance directives have been used

mainly to limit treatment, requests for treatmentmay cause conflicts between competent individu-als' wishes and the health services that areavailable to them once they become incompetent.For example, advance directives asking for scarcetreatments may be overridden when a "just level"of care is exceeded and others are being deniedresources." Patient choice also may be limitedwhen treatment is too costly, especially given thatother health needs are not met.23

Accordingly, under a universal health care planlike that in Canada, the autonomy of patients whodemand services that are not provided under theunified public plan might be restricted.24 In otherwords, patients might not have a legitimate claimto treatment that is being withheld as part of a justrationing system.25 Privileging the value of au-tonomy runs against a principled way of limitingthe medical services that ought to be guaranteedto all individuals.26 Even in Canada where theemphasis on universal access to health careservices is based on collectivist principles that callfor social responsibility for the basic welfare of itsmembers,27 a significant dilemma exists since thestate both protects individual autonomy byproviding for an individual's welfare and threatensit by making allocation dependent on the consentof the plurality.28The promotion of autonomy in advance care

planning must be understood not as a guaranteethat the patient will get whatever he or she wants,but rather as "the responsible use of freedom"9according to which the right course of action isnot always one that promotes his or her owninterests. This has been described as a "sociallyresponsible" approach to advance directives ac-cording to which the patient is viewed as bothcitizen and consumer and patient self-determination is understood in the context of"informed consent" rather than in the context of"consumer sovereignty".25 A "citizen ethic" ac-cording to which the patient is viewed as a citizenwith rights within the health care context alongwith duties to make judicious and proportionatechoices also has been proposed.29Though critics often assume that autonomy is

the trump value within liberalism, leaving little orno room for an account of justice and equitableresource allocation, this is not a valid assumption.The contemporary liberal objective may besummarised as follows: ifwe are to treat people as

equals, we must protect them in their possessionof certain rights and liberties.30 Much has beenwritten within liberalism on the question of whichrights and liberties these are, but the moraldemand of liberal equality is held prior to that ofthe protection of our (individual) rights andfreedoms.

Justice as fairness, understood in terms of anequal share of social goods, namely, equal libertiesand opportunities, is the very crux of modernliberalism.3' Modern liberals reject the claim thatliberalism is committed merely to economicgrowth; the government required to ensure thisgrowth, and a conception of life in which growth ispursued for its own sake in the form ofcompetition, individualism, and materialpursuits.32 Liberty is an important value but whatis valued fundamentally is equal liberty for all citi-zens. Liberalism is a political theory based on anegalitarian conception of justice. Liberal theory isthus able to take into account the concerns forequitable resource allocation that may arise inadvance care planning.

Objection III: liberal autonomy does notaccount for justifiable acts ofpaternalismThe third major objection to liberal autonomy isthat it is very difficult, if at all possible, for liber-als to justify paternalistic acts. This poses a prob-lem in defining a liberal account of advance careplanning since substitute decision makers aresometimes justified in treating incompetentpatients paternalistically when to honourpatient's wishes as expressed when competentwould pose an unnecessary risk to the patient'spresent welfare.

Liberals insist that in order to lead a good life"every competent adult be provided with a sphereof self-determination which must be respected byothers"33 and that "for those who pass the thres-hold of age and mental competence, the right tobe self-determining in the major decisions in life isinviolate".33 However, the modern liberal princi-ple of autonomy must be qualified by a paternal-istic principle of wellbeing. Paternalistic acts maybe justified in our relationships with children, thedemented, the otherwise temporarily incapaci-tated, and even, under certain circumstances, inour relationships with competent adults whoexhibit "weakness of will" in doing what is in theirbest interests."4

Liberals call attention to the distinction between"hard paternalism", which justifies the impositionof values and judgments on people "for their owngood", and "soft paternalism" which holds that thestate has the right to prevent self-regarding harm-

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ful conduct when that conduct is non-voluntary (a"non-voluntary" act is one for which consent is"missing because the subject...is incapable ofgiving his voluntary consent").35 Soft paternalismis a principle which suitably qualifies liberalismsince it permits interference in the absence of vol-untary consent. Soft paternalism defends thosewho are unable to give voluntary consent againstthreats to their autonomous self, which is quiteanother thing than throttling that autonomous selfwith external coercion. It may even defend thosewho are no longer "the same person" as the personwho issued the advance directive. (This touchesupon a further argument against advancedirectives-that they often apply to people who aredifferent from those who executed them; a fullconsideration of this primarily metaphysical argu-ment is beyond the scope of this article.)36 37 Inter-ference on this ground is no more illiberal thaninterference to prevent one from harming anunwilling second party.38

Liberalism may thus be qualified by a principleof soft paternalism in the form of overriding theadvance directives of patients who are nowincapable of providing voluntary consent to avail-able health care options. The choices expressed bypatients while competent may not have been vol-untarily made due to, for example, coercion andbias from health care professional(s) and/or familymembers. Paternalistic decision making may beacceptable under such circumstances to defendthe patient against threats to his or her autono-mous self.The choices expressed by patients while compe-

tent may not have been adequately informedeither-had they foreseen and understood thenature of their now present condition, suchpersons may have chosen otherwise. Paternalisticdecision making may be acceptable under suchcircumstances in order to do what is in thepatient's current best interests.

Soft paternalism is regarded as an "alternative,essentially liberal, rationale for most of whatseems reasonable in paternalistic restrictions".39Insofar as it is qualified by a principle of paternal-ism in defence of overriding patients' previouslyexpressed choices, at least where those choiceswere not voluntary and/or informed and nowthreaten their wellbeing, contemporary liberalismis able to account for justifiable acts ofpaternalismwithin the process of advance care planning.

Objection IV: liberal autonomy does notaccount for the importance ofpersonalrelationshipsThis last objection is especially pertinent in lightof recent empirical research highlighting the

importance of personal relationships in advancecare planning. In a qualitative study of 48 patientsreceiving haemodialysis, we showed that thetraditional academic assumptions are not fullysupported from the perspective of patientsinvolved in advance care planning. The patientswe interviewed stated that: 1) the purpose ofadvance care planning is not only preparing forincapacity but also preparing for death; 2)advance care planning is not based solely onautonomy and the exercise of control, but also onpersonal relationships and relieving burdens onothers; 3) the focus of advance care planning isnot only on completing written advance directiveforms but also on the social process, and 4)advance care planning does not occur solely

*within the context of the physician/patient rela-tionship but also within relationships with closeloved ones.' In a subsequent qualitative study of140 people with Human Immunodeficiency Virus(HIV), we showed the primary goal of advancecare planning was: preparing for death, whichentailed facing death, achieving a sense of control,and strengthening relationships.6

It has been argued from within feminist theorythat the overemphasised individualistic ethicwhich critics associate with liberalism, demandsthe denial of the value ofpersonal relationships forautonomous choice. The (liberal) concept ofautonomy, it is claimed, carries too many associa-tions of isolation and independence in itsportrayal of personhood to capture feministconceptions of agency.40 As in the case of the firstobjection considered earlier, liberalism is chargedwith defining atomistic individuals as the basicunits of political and legal theory. The furtherobjection here, however, is that liberalism thusfails to recognise the inherently social nature ofhuman beings and the "relatedness" that is a pre-condition of autonomy.4'For example, relational theory, offered by

"feminine theorists" from within feministtheory,42 argues that although appropriate torelationships between strangers and to purelyprofessional relationships, emphasis on (liberal)autonomy is not appropriate to relationshipsbased on "connectedness", or "caring".43 Theconcern for the value of personal relationships iscaptured in a morality of care that challengesjustice-based theories of moral development andjudgment44 (ie, those associated with the liberaltradition). Such theories have been rejected as"masculine" approaches to moral decision mak-ing and ethical analysis having little, if any,concern for the interests of women.43 Moreover,they are often viewed as the presumption ofWestern (liberal) medical ethics which "often

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relies on ... the context of justification for ethicaldecision making rather than the context withinwhich such decision making takes place... .

Consequently, relational theorists have argued forthe importance of context-based values such asthat of personal relationships rather than ab-stract, universal principles. For example, it hasbeen argued that an ethic of care is more appro-priate as the foundation for theories of medicalethics than the liberal values of justice andautonomy in accounting for the significance ofthe value of personal relationships.46

It may be, however, that liberalism does not failas a theoretical framework for the value ofpersonal relationships for autonomy since it hasnever been its intention to serve in this role. Lib-eralism (with its ideal of state neutrality and"negative" conception of freedom) is best consid-ered a political doctrine.47 The liberal concern forpolitical relationships reflects a deeper agenda toprotect the private choices and affairs of individu-als. Modern liberalism therefore may have rel-evance for a theoretical account of advance careplanning, not in terms of the promotion of thevalue of personal relationships, but rather in termsof its preservation and protection. Liberal writersdo not discuss the nature and value of personalrelationships, as such, though they may seek todefine a liberal account of the individual assituated or embedded in community and culture.This suggests that liberalism is not inconsistentwith an account of the nature and value ofpersonal relationships in advance care planning. Itis not inconsistent with the concerns and goalspeople who engage in advance care planning havethat relate to the impact of their decision makingon others.However, a relationship ethic serves specifically

as an account of the importance of personal rela-tionships in the process of advance care planning.After all, such an ethic has explanatory powerinsofar as it defines moral decision making, forinstance regarding certain decisions about futurecare, as part of particular and concrete situationsin which individuals are engaged in networks ofrelationships with others. Insofar as it lacks a rela-tionship ethic of this kind, modern liberalismremains insufficient in accounting for theimportance of personal relationships as a factor inadvance care planning.

ConclusionFour objections suggest that the liberal value ofautonomy is inappropriate as a basis of advancecare planning. These objections are that the liberalconcept of autonomy (i) implies a misconceptionof the individual self, (ii) entails the denial of

values of social justice, (iii) does not account forjustifiable acts of paternalism, and (iv) does notaccount for the importance of personal relation-ships in the process of advance care planning. Wehave examined these four objections to autonomy,and the liberal theoretical framework with which itis associated, in order to re-evaluate the philo-sophical basis of advance care planning.We have argued that (i) liberal autonomy is not

a misconceived concept as critics assume. Thougha necessary component of a theoretical account ofthe concern for personal control that personsengaged in advance care planning may have,liberal autonomy entails recognition of the socialaspects of personhood and thus the social compo-nents of advance care planning. We have alsoargued that liberal autonomy (ii) does not entailthe denial of values of social justice and that it (iii)can account for justifiable acts of paternalism inconsideration of a patient's advance directive.With respect to the objection that liberalism (iv)does not account for the importance of personalrelationships in the process of advance care plan-ning, we acknowledge that liberalism remains aninsufficient framework in terms of its lack of directfocus on the value of personal relationships thatare a factor in the process. In closing, we suggestthat contemporary liberalism needs to be supple-mented with theoretical accounts-such as thatoffered by relational theory that pay specificattention to the value of personal relationshipstowards the development of a full theoreticalframework for advance care planning.

AcknowledgementsThe authors are grateful to James Lavery, DouglasMartin and Barbara Secker for their commentsand suggestions and to Professor Wayne Sumnerfor supervising Sharon Ikonomidis's doctoralthesis. This research was supported by the Physi-cians' Services Incorporated Foundation of On-tario. Dr Singer was supported by a NationalHealth Research and Development ProgramScholar award and is now supported by a MedicalResearch Council of Canada Scientist award.

Sharon Ikonomidis, PhD, is a Doctoral ResearchGraduate of the University of Toronto 70int CentreforBioethics. PeterA Singer, MD, MPH, FRCPC, is SunLife Chair in Bioethics at the University of Toronto,Director of the University of Toronto 70int Centre forBioethics, Professor ofMedicine, University of Torontoand a Staff Physician at The Toronto Hospital. Pleaseaddress all correspondence to: Dr Peter A Singer, SunLife Chair in Bioethics and Director, University ofToronto Joint Centre for Bioethics, 88 College Street,

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Toronto, Ontario, M5G 1L4, CANADA, tel: 416-978-4756, fax: 416-978-1911, e-mail: peter.singer@utoronto. ca

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