Letters

To the Editor:

In "Conscientious Autonomy: Displacing Decisions in Health Care" (HCR, Mar-Apr 2005), Rebecca Kukla argues persuasively that it's a mistake to equate autonomy with the ability to make self-originating, informed, punctate decisions. Often, she points out, we defer to those who can reasonably be assumed to have more authoritative knowledge than we do regarding some particular practice. Deference and trust of authority are crucial virtues not only for patients who participate in the practice of health care, but for students participating in the practice of education, ordinary drivers participating in the practice of car maintenance, passengers participating in the practice of air travel, and so on. That uncritical deference to authority can sometimes be a moral failing does not undermine Kukla's point: genuine exercises of autonomy routinely involve trusting those who have expert knowledge.

Kukla is also right, I think, to argue that autonomy extends beyond punctate decisions. On her thoroughly social conception, autonomy is not so much a matter of what I freely and knowledgeably decide now, at this point, but how a particular "we" engages in taking, assigning, deflecting, and ducking responsibility within a specific practice—all of which determines who is accountable in the practice, to whom, and for what. Practices may need to be altered so that the "we" in question can engage in them responsibly, as is revealed by her example of pregnant women willing to take the maternal serum alphafeto protein test despite lack of benefit to them or their future children.

Kukla's reflections on the social nature of autonomy lead me to wonder, though, if the concept of autonomy she opposes is properly characterized as self-determination. Her quarrel, after all, isn't with the thought that autonomy involves authority over one's own body, or, more broadly, the authority to determine how one's life should go. She just thinks that this authority is socially mediated. And if, as philosophers from Ludwig Wittgenstein to Annette Baier have argued, the self is essentially social, then surely self-determination is social as well. It seems to me that what Kukla means to fault isn't self-determination but rather self-sufficiency—another concept with which autonomy is routinely confused. Self-sufficient people—which most of us aren't—answer to no one. They are the sole locus of their decisions and actions, and they reason on the basis of their own knowledge—the two conditions Kukla sets out for the conception of autonomy she rejects. What's often overlooked about self-sufficiency is that it typically requires cleaners, child minders, cooks, administrative assistants, and others to be invisibly in place (and therefore unacknowledged) so that some people can have the appearance of it. Now that's a notion of autonomy we can all do without.

Hilde Lindemann

Michigan State University

To the Editor:

Rebecca Kukla's recent article is an ambitious—and vitally needed—attempt to advance current thinking on what patient "autonomy" in medical care would involve if it existed. Her alternative framework derives from the assumption that patients' medical decisions are formed within broader, ongoing social activities, both health-related and not. She's certainly correct to assert that researchers and theorists working on the subject have focused too narrowly on informed consent and that much of what we term "health care" does not involve any decision-making.

I was intrigued by her argument that an "autonomous" medical decision can sometimes involve simple deference to medical authority, but I'm still unclear what she means when she says that such decisions can be construed as conscientiously autonomous if derived from a patient's "self trust." This seems precisely the paradox at the heart of debates over the existence of free will, or in Kukla's rubric, autonomous choice: is there a "space" outside of social life constituting individual desires where choices derive from what one "really" wants?

My own recent research on pregnant Latinas' amniocentesis decisions finds that many consent to the test in deference to medical authority. As one interviewee explained, "Why...