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In this chapter, I provide the account of autonomy that will inform claims that doctors are morally required to promote this trait in their depressed patients. I set out agency and liberty as foundational elements of autonomy and then elaborate four contemporary theories that stipulate the kinds of desires compatible with actions under full agential control. While accepting that autonomy requires actions to cohere with desires and values the agent endorses as his or her own, I argue that conceptual difficulties with desire-based theories limit their clinical utility. For this reason, I focus on the nature of the beliefs an agent must hold for his or her related actions to be autonomous. I argue that justified beliefs concerning material facts are necessary for autonomous choice and that autonomy can be quantified by enumerating those material facts that are fully understood by the agent. I go on to explain how autonomy accrues value on both instrumental and intrinsic accounts before showing that value to be a source of the normative weight accorded the principle of respect for autonomy. The view of autonomy presented here will be developed in the next chapter, where I argue that an understanding of the emotional response is central to a full account of personal autonomy. 2.1 Autonomy: Fundamental Principles and Four Contemporary Accounts The term “autonomy” has its roots in the Greek autos meaning “self” and nomos meaning, “rule,” “law,” or “governance.” The original usage of autonomy was as a descriptor for Greek city-states that were selfdetermining and not subject to the law or will of another state.1 The notion of personal autonomy extends this earlier political conception to the individual . Thus, an autonomous individual can be thought of as someone who “governs” himself or herself, rather than being dictated to by another. Autonomy: The Importance of Justified Beliefs about Material Facts 2 10 Chapter 2 Those who are compelled always to act at the behest of others are not autonomous but heteronomous. As with political governance, individual self-governance emphasizes an overarching credo, plan, or set of values with which the actions of the individual cohere. Most conceptions of autonomy embrace two elements, liberty and agency.2 Isaiah Berlin has argued that liberty has both a negative and a positive sense.3 In its negative sense, liberty implies freedom from external impediments to intentional action. Negative liberty is widely held to be a necessary condition for autonomy. Thus, the person who is imprisoned or enslaved, being paradigmatically unfree, is also deprived of autonomy. However, as Robert Young has pointed out, liberty in this negative sense is not sufficient for autonomy.4 The slave does not become autonomous simply by virtue of being released from the bonds of slavery. If, for example, during bondage the slave became mentally or physically impaired, perhaps as a result of illness, then, although later free, he or she is not necessarily autonomous. A fuller account of autonomy invokes the notion of positive liberty. It requires that individuals be assisted in achieving self-determination through the provision of appropriate resources. Consider a variation on Locke’s case. A person is placed in a room believing its only door to be locked when in fact it is unlocked. In one sense the person is quite free to leave but in another sense is not. The person is “free” in a negative sense as there are no physical barriers to leaving the room. However, without knowing the door is unlocked, he or she is deprived of liberty in its more positive sense.5 Agency, the second broad requirement for autonomy, can be thought of as the capacity for intentional action.6 The notion of agency conveys the sense of a power to act and implies an authority over oneself based on an ability to formulate plans and to carry them out. Agency demands a capacity to rationally process the information that grounds beliefs, desires, and ultimately, our motivations to act. A lack of agency is the primary contributor to the diminished autonomy of the freed slave with mental or bodily impairment. In recent decades four accounts have been particularly influential in further molding the concept of personal autonomy. Each has its foundation in notions of liberty and agency but attempts to refine, in particular, the kinds of desires that might form the basis for a satisfactory account of autonomy. Hierarchical theories, proposed by Gerald Dworkin,7 Harry Frankfurt,8 and others,9 are so named because they emphasize concordance...

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