Concepts at the Bedside: Variations on the Theme of Autonomy

This article examines the patient/clinician conversation when there is disagreement about the values at stake in the treatment decision. To set the stage for that examination, three cases of refusal of treatment are considered, which point to three ways of understanding the content and value of autonomy. In the patient/clinician conversation, the clinician must inevitably adopt one of these conceptions of autonomy, but if he or she adopts a conception that puts significant weight on having rationally defensible values determine the treatment decision, there is still a limit to how far the clinician may challenge the patient’s values. Through an appeal to John Rawls’s criterion of political legitimacy, the author argues that the clinician may challenge the ordering of the values he or she shares with the patient, but that the clinician may not challenge the content of the patient’s fundamental—or life-guiding—beliefs.