Deciding Who We Are : The Relational Self and the Tyranny of Atomistic Autonomy

In a court decision in 1914 Benjamin Cardozo wrote that every human being of adult years and sound mind has a right to determine what shall be done with his own body.... Now known as the right or principle of autonomy, this concept pervades the law, undergirding virtually all rights relating to the body, particularly those grounded in the right of privacy. Nowhere is this clearer than within the realm of healthcare law and ethics where patient autonomy has become the dominant principle governing healthcare decision-making. We live in the time of the triumph of autonomy....This primacy of autonomy has been widely criticized by a wide variety of thinkers. Its inadequacies become particularly apparent when the person involved suffers from a cognitive impairment like dementia. What does it mean to say that a person has a right of self-determination when they lack the mental capacity to make even routine decisions such as what to eat, when to eat or even how to eat? On a practical level, how does the concept of autonomy help us make necessary treatment decisions for the demented person? The concept frames the issue in ways that provide no answers to these questions.More fundamentally, respect for autonomy expresses a particular understanding of who we are and what it means to be human. Some use it to distinguish humans from the animals and all other living creatures. The fact that we are rational beings capable of recognizing ourselves, our wants and our desires, and acting upon our rational determination of those wants and desires defines us as members of the human community. Intuitively, this is how we understand our own existence. However, if this is true, at what level of rational self consciousness do we attain human status? Conversely, does the loss of reason exclude us from the human community? If so, how much rational self consciousness may be lost before we lose our status as members of the human moral community?If we reject this view, as we must, then how might we re-conceive our understanding of ourselves in a way that is both attentive to our lived experience and to the reality that some human beings may lose (or never attain) rational capacity yet remain within the moral community of humans? Does our nature as social beings offer any help? How can this address the problems we discover when we carefully consider the inadequacy of autonomy as a basis for moral standing and worth?