R. Moshe Feinstein and the Role of Autonomy in Medical Ethics Decision Making

Introduction

Professor J.B. Schneewind has convincingly argued that the dominant theme of modern moral philosophy is the ethical justification of the change from a morality based on obedience to one based on self-governance.¹ Before the eighteenth century, morality was understood as one aspect of the obedience owed to God. In this formulation, God's will is known to us through reason and revelation as interpreted by the clergy. Most people need to be instructed in the proper ethical behavior and threats of punishment and possibility of reward are needed to ensure compliance. The new view argued that all of mankind is able to live together based on a morality of self-governance. In this perspective, all men have the ability to behave in a moral manner without the threat of punishment or offer of rewards. Central to this new outlook was the work of Kant who provided an intellectual framework for the morality of self-governance. Man is endowed with pure practical reason which enables him to make moral decisions based on what would be the right thing for any person to do in similar circumstances. From this knowledge comes categorical imperatives which guide a person's ethical behavior irrespective of the particulars of the situation or the expected consequences. Kant sided with the intellectualists in their dispute with the voluntarists in maintaining that there is a rational moral Law independent of God but, nevertheless, he did assign God the role of assuring that virtue is ultimately rewarded and evil punished.

However, Jeffrey Stout has argued that this modern idea of autonomy is primarily based on a "flight from authority," and in particular religious authority.² This philosophy of autonomy has been almost universally accepted by contemporary moral philosophers and serves as the foundation of much of modern ethics. In the words of Peter Berger "the theme of individual autonomy is perhaps the most important theme in the worldview of modernity."³

Bioethics and Autonomy

While modern bioethics was relatively late in accepting the value of personal autonomy in medical decision-making, it is now universally recognized as the dominate theme in Western medical ethics. As late as 1940, the American Medical Association (AMA) code of ethics maintained that disclosure is recommended, but not to the patient. The acceptance by Western medicine of autonomy as the focal point of modern bioethics was partly a response to the notorious experiments performed by Nazi doctors on concentration-camp inmates. These include Mengele's experiments on 1500 sets of mostly young twins at Auschwitz and the infamous hypothermia experiments at Dachau where 300 prisoners were held in freezing water for as long as seven hours resulting in 90 deaths. These human experiments were unique in biomedical science because death of the participant was an expected, and even sought after, outcome and obviously the subjects were unable to refuse to participate. The organized medical community was profoundly shocked by the involvement of physicians in these crimes and an international effort led to the development of the Nuremberg Code whose first principle states: "The voluntary consent of the human subject is absolutely essential" for any research involving human subjects. This was followed by the first World Medical Association Declaration (WHO) of Helsinki (1964) which provided recommendations to physicians on research involving human subjects. It asserts that the subject "should be informed that he or she is at liberty to abstain from participating in the study and that he or she is free to withdraw his or her consent to participation at any time." This document's focus is on research ethics and places major emphasis on the doctrine of autonomy and informed consent. The potential research subject has to be fully informed of the potential risks and benefits of the proposed research and must give his or her consent without undue coercion or pressure. In addition, there must exist no negative consequences of non-participation. Notwithstanding the almost universal acceptance of these principles, reports of cases of unethical research design and practices in clinical trials still plague the biomedical community.

Jay Katz and...