Rethinking Autonomy: A Critique of Principlism in Biomedical Ethics

Chapter 7 Rethinking Autonomy

Chapter 7 Rethinking Autonomy . . . autonomy cannot be an absolute principle with a priori precedence over other prima facie principles. Rather, the judicious exercise of respect for autonomy means that health professionals must act in a manner that enables and empowers patients to make decisions and act in a way that is most in accord with their values. —Pellegrino (1992:1735) When the great earthquake and tsunami (Tôhoku Daishinsai 東北大震災) devastated the northeastern coast of Japan, many reporters in the American news media showed surprise at the response of the Japanese people living in that area. The lack of criminal activities such as looting and the general orderliness and willingness to help others seemed to impress many in the United States. Shortly after the disaster, I was interviewed by a reporter from the Houston Chronicle about the response of Japanese people and the ways in which that response was shaped by Japanese culture . Comments posted by readers after the article was published online were intriguing. JimFromTexas wrote, “The Japanese culture kicked in immediately—manners, helping others, polite, respect for the elderly, sharing, etc. Oh that America had some of that!” while a person who goes by Standeck wrote, “The Japanese do adversity well; when disaster strikes, they come together, knuckle down and deal with it. On the downside of that community spirit, you can move to and live in Japan 135 136 Rethinking Autonomy for decades, but you will never be ‘Japanese.,’ ”1 Other comments were less positive, such as one individual who wrote that God was somehow punishing the Japanese—for reasons not made clear in the comment. And another person who goes by the ironic name “Contemplate” wrote, “What Ms Dooley [the writer of the article] reports with terms pulled from the Marx primers is what she’s confused with the reaility [sic] of: tradition, love, sharing, and many more traits that are often found in the bible (SHHH. don’t tell her that last bit!).2 Of course, the Japanese reaction to the earthquake/tsunami has nothing to do with the Bible and nothing to do with the Christian god; indeed, one of the more salient aspects of the aftermath of the disaster was its powerful illustration of the fact that neither strong religious beliefs nor Christian ideologies are a necessary foundation to moral order—as Reader (1991:14)3 notes, most Japanese exhibit a considerable “reticence . . . to affirm religious belief.” The reaction of Japanese following the disaster certainly does have something to do with culture, and specifically with the manner in which people in Japan conceptualize notions of individuality and autonomy. Pellegrino, cited above, is right that autonomy should not be treated as an absolute principle, and as I have argued throughout this book, we need to move further in the direction suggested by Pellegrino’s comments and question exactly what it means to talk about autonomy in different cultural contexts. The case of northeastern Japan following the disaster provides an interesting contrast in how values are expressed, particularly when set against the actions of some individuals involved in the Hurricane Katrina disaster in New Orleans.4 At issue here is not so much one of community spirit or a tradition of love and sharing, although a community spirit is certainly 1. It is worth noting that I have heard many immigrants make the same comment about living in the United States. No matter how long they are here, they never feel like “Americans.” 2. The article is available on the Houston Chronicle website at http://www.chron.com/ disp/story.mpl/life/main/7478650.html and the comments are at http://www.chron.com/ disp/discuss.mpl/life/main/7478650.html. Both were accessed for this chapter on March 30, 2011. 3. See also Reader and Tanabe (1998). 4. It is easy, however, to let the actions of those individuals overshadow the considerable sense of charity and community help that also arose after Katrina. A sense of community, although it will vary, can arise in a variety of cultural settings—even ones that tend to isolate individuals. 137 Rethinking Autonomy a product of the more fundamental issue of how Japanese think about the individual and the capacity of individual selves to make autonomous decisions. More importantly is that in contrast to the United States, where autonomy is constructed largely as an isolating ideology that emphasizes the rights of individuals, in Japan autonomy is seen...