Hastings Center Report, Januay/Febmay 1990

sort, harder to specify but I think

more fundamental, rooted in that
other form of moral life described by
Oakeshott. Our rationalistic theoret-
ical activities, for all their clarity, are
by their very abstractness incapable
of contributing to the increase or
renewal of that capital. Indeed, our
activities are in danger of undermin-
ing it, sometimes explicitly by the
condescension shown by self-
conscious theory for habitual practice
and sentiment, more often by sheer
indifference or neglect. We may, in
the end, be incapable of stemming
the rationalist prejudice, so prevalent
in our age, or of restoring those
institutions that lay the moral foun-
dations of private and public life. But
wewould be at fault for not seeing
the need to do so.
The Hastings Center, and the field
it helped to launch, both now well-
founded, face a not atypical problem
of perpetuation: how to provide for
the kinds of people and moral
concerns that got it started. Henry
Beecher, Paul Ramsey, Hans J onas,
Robert Morison, Dan Callahan, and
Will Gaylin were, I repeat, not brought
up on bioethics or moral theory, and
no academic training accounts for
their vision, courage, and moral
passion. They have helped institu-
tionalize a world of ethical discourse
that might give the impression that
their moral beginnings are no longer
necessary. Nothing could be further
from the truth. We must return to
what animated the enterprise: the
fears, the hopes, the repugnances, the
moral concern, and, above all, the
recognition that beneath the distinc-
tiveissues of bioethics lie the deepest
matters of our humanity. As we
celebrate our present, we must look
seriously into the Centers begin-
nings, to revitalize ourselves for the
work of our future.
The Place of Autonomy
in Bioethics
by James E Childress
I come not to bury autonomy, but
to praise it. Yetmypraise is somewhat
muted for autonomy merits only two
cheers, not three. Fiveyears ago at
the fifteenth anniversary of the
founding of The Hastings Center the
general theme was Autonomy-
Paternalism-Community. Hearing
several sharp criticisms-indeed,
virtual rejections of autonomy-I
stressed in myoral remarks and later
in my published paper that weneed
several independent moral princi-
ples, such as individual and commu-
nal beneficence and respect for
personal autonomy. It is unfortu-
nate and even pernicious, I con-
tinued, to suggest that biomedical
ethics is allegedly moving beyond
autonomy to community and pater-
nalism, for such an approach would
reduce ethical reflection to a mere
mirror of societal concerns at a
particular time, when in fact the task
for serious ethical reflection is to
indicate the importance and relative
weight of several moral considera-
tions that should be maintained in
some tension or balance.
Reaffirming that statement five
years later, I want to defend the
principle of respect for personal
autonomy as one among several
important moral principles in bio-
medical ethics. My defense will
proceed by sketching and clarifying
some presuppositions and implica-
tions of this principle in light of
several major criticisms. Many of
those criticisms are misplaced,
because they are (perhaps deliber-
ately) not directed at the most de-
fensible conceptions of the principle
James E chilclt.pss is professor of religious
studies and medical education and
chairman, the Depart mt of Religious
Studits, Universig of Erginia, Charlot-
tesville) VA
of respect for autonomy. I will
contend that an adequate conception
of the principle of respect for auton-
omy can meet the main criticisms
levelled by various critics, whether
communitarians, narrativists, virtue
theorists, traditionalists, or religion-
ists. My main argument focuses on
the pznciple of respect for autonomy as
an important moral limit and as limited.
As a moral limit, it constrains actions;
but it is also limited in scope and in
weight, in addition to being complex
in its application. Both critics and
defenders tend to neglect these
senses of limit in their focus on an
oversimplified, overextended, over-
weighted principle of respect for
autonomy.
Misdirected criticisms
In several ways, the principle of
respect for autonomy has been
misunderstood and misinterpreted,
in part as a result of flawed formu-
lations and defenses by its supporters.
Critics have often supposed that they
were attacking the concept of auton-
omy when in fact they were aiming
their fire at particular conceptions of
autonomy, often the least defensible
ones.
It has been a mistake to use the
term autonomy or even the phrase
principle of autonomy as a short-
hand expression for the principle of
respect for autonomy.* It is impor-
tant to correct this mistake because
many critics seem to suppose that
proponents of this principle have an
ideal of personal autonomy and
believe that we ought to be auton-
omous persons and make autono-
mous choices. However, the ideal of
personal autonomy is neither a
presupposition nor an implication of
the principle of respect for personal
autonomy, which obligates us to
12
Hastings Center Report Janua y/Febr ua y 1990
respect the autonomous choices and
actions of others.
The ideal of autonomy must be
distinguished from the cunditzoru for
autonomous choice. It is important
for the moral life that people be
competent, be informed, and act
voluntarily. But they may choose, for
example, to yield their first-order
decisions (that is, their decisions
about the rightness and wrongness
of particular modes of conduct). For
example, they may yield to their
physicians when medical treatment is
proposed or to their religious insti-
tution in matters of sexual ethics.
Abdication of first-order autonomy
appears to involve heteronomy, that
is, rule by others. However, if a person
autonomously chooses to yield first-
order decisionmaking to a profes-
sional or to a religious institution, that
person has exercised what may be
called second-order autonomy.g Peo-
ple who are subservient to a profes-
sional or to a religious institution may
lack first-order autonomy-self-
determination regarding the content
of their first-order decisions and
choices-because they have exer-
cised and continue to exercise
second-order autonomy in selecting
the professional or institution to
which they choose to be subordinate.
Hence, in those cases, respect for
their second-order autonomy is
central, even though their first-order
choices are heteronomous. This
point is important because of the
common supposition that the prin-
ciple of (respect for) autonomy is at
odds with all forms of heteronomy,
authority, tradition, etc.
The term respect also requires
amplification. One meaning of
respect is to refer to or have regard
for or to consider. For example, a
boxer may respect his opponents
right hook. A second meaning is more
relevant-to consider worthy of high
regard, to esteem, or to value. This
meaning reflects the attitude that is
proper in relation to autonomous
choices. Although this attitude does
not depend on the content of those
choices, it is not inconsistent with
criticismof them. In a third sense,
respect is more than an attitude, it
is an act of refraining from interfering
with, or attempting to interfere with
the autonomous choices and actions
of others, through subjecting them to
controlling influence, usually coer-
cion or manipulation of information!
The principle of respect for auton-
omy can be stated negatively as it
is [prima facie] wrong to sutject the
actions (including choices) of others
to controlling influence. This prin-
ciple provides the justificatory basis
for the right to make autonomous
decisions. This right in turn takes the
form of specific autonomy-related (if
not autonomy-based) rights, such as
liberty and privacy. This negative
formulation focuses on avoidance of
controlling influences, including
coercion and lying. However, the
principle of respect for autonomy also
has clear positive implications in the
context of certain relationships,
including health care relationships.
For example, in research, medicine,
and health care, it engenders a
positive or affirmative obligation to
disclose information and foster
autonomous decisionmaking. Never-
theless, it is important to distinguish
negative and positive rights based on
or related to the principle of respect
for autonomy, and the limits on
positive rights may be greater than
the limits on negative rights. For
example, the positive right to request
a particular treatment may be severely
limited by research protocols and by
just allocation schemes.
Finally, the principle of respect for
autonomy is ambiguous because it
focuses on only one aspect of per-
sonhood, namely self-determination,
and defenders often neglect several
other aspects, including our embod-
iment. A strong case can be made for
recognizing a principle of respect for
persons, with respect for their
autonomous choices being simply
one of its aspects-though perhaps
its main aspect. But even then we
would have to stress that persons are
embodied, social, historical, etc. Some
of these issues emerge when we try
to explicate the principle of respect
for autonomy by noting its
complexity.
Complexity of Respect for Personal
Autonomy
In determining what the principle
of respect for autonomy requires, it
is important to recognize its complex-
ity, which is widely neglected by both
defenders and critics. Some of my
earlier remarks highlighted aspects of
this complexity-for example, the
distinction between first-order and
second-order choices. Because of the
complexity of persons, judgment is
required, rather than the mechanical
application of a clear-cut moral
principle.
One difficulty in respecting peo-
ples choices is determining what they
are choosing, what preferences they
are expressing, etc. This complexity
is magnified because people commu-
nicate not only through written
statements (such as signed consent
forms) or through words, but through
nonverbal signs as
Furthermore, patients may be
ambivalent or even express contra-
dictory preferences. In the maze of
signals, the professional may have to
make a judgment about whether a
patient really wants full or only partial
disclosure, or really wants to undergo
a test to determine whether he could
donate a kidney to a sibling, etc.
Another major difficulty in respect-
ing personal autonomy stems from
the fact that people exist in and
through time and their choices and
actions occur over time. Consent itself
is given and withdrawn over time and
a patients present statements should
not always be taken at face value.
Hence in discharging our obligations
under the principle of respect for
autonomy, we not only have to
determine whether a patient is
autonomous and just what he or she
is choosing, wealso have to put that
patients present consents and dis-
sents in a broad temporal context
encompassing both the past and the
future. As temporal beings through
and through, people may express
different preferences at different
times. Often discussion of the prin-
ciple of respect for autonomy focuses
on the present moment-for exam-
ple, is there an informed consent or
refusal at this time? Respecting
persons becomes very complex when
their temporality is properly included.
Which choices and actions should we
respect? In particular, is it justifiable
to ovemde a patients present auton-
omous choices and actions in the
light of hidher past or (anticipated)
future choices and actions? And is a
13
Hastings Center Report, January/Februa y 1990
decision to do so respect for personal
autonomy or a paternalistic breach
of the principle of respect for
autonomy?6
Past or prior consent/refusal poses
no problem if the patient cannot
currently autonomously express his
or her wishes. As in the case of
advance directives, we respect per-
sonal autonomy by acting on that past
or prior statement. Matters become
more problematic, however, when a
persons present choices appear to
contradict those previous choices,
which may have even been made with
a view to preventing future change.
For example, in one case a twenty-
eight-year-old man decided to termi-
nate chronic renal dialysis because
of his restricted lifestyle and the
burdens on his family-he had
diabetes, was legally blind, and could
not walk because of progressive
neuropathy. His wife and physician
agreed to provide him medication to
relieve his pain while he died and
agreed not to put him back on dialysis
even if he requested it under the
influence of uremia, morphine sul-
fate, and ketoacidosis (the last result-
ing from the cessation of insulin).
While dying in the hospital, the
patient awoke complaining of pain
and asked to be put back on dialysis.
The patients wife and physician
decided to act on the patients earlier
request that he be allowed to die, and
he died four hours later. In my
judgment, the spouse and physician
should have put the patient back on
dialysis in view of his current request
and the irreversibility of the decision
to let him die in accord with his earlier
statements. After putting him back on
dialysis, they could have determined
if he had autonomously revoked his
prior choice; if he then persisted in
his prior decision, they could have
proceeded again with more
confidence.
A critical question in this case and
others is whether people have auton-
omously revoked their previous
consents/refusals. Thus, it is neces-
sary to continue to assess a persons
degree of autonomy over time to
determine whether he or she is
autonomously revoking previous
consents or dissents. The principle of
respect for autonomy requires that we
attend to both a persons prior
consent/refusal and present revoca-
tion, but the present revocation takes
priority if it is autonomous.
What is the role of authenticity in
judgments about which actions
respect personal autonomy? The
consistency or inconsistency of a
present choice or action with a
persons life plan and risk budget over
time may help us detemiine whether
the revocation is genuine. For Bruce
Miller, authenticity means that an
action is consistent with the attitudes,
values, dispositions and life plans of
the person.* Its intuitive idea is
acting in character. We wonder
whether actions are autonomous if
they are out of character (for exam-
ple, a sudden and unexpected deci-
sion to discontinue dialysis by a
woman who has displayed consider-
able courage and zest for life despite
years of disability). Similarly, we are
less likely to challenge actions as
nonautonomous if they are in char-
acter (a J ehovah Witnesss refusal of
a blood transfusion, for example).
Nevertheless, as important as the idea
of character is, it would be a mistake
to make authenticity a criterion of
autonomy. At most, actions appar-
ently out of character and inauthentic
can be caution flags that warn others
to request explanations and justifica-
tions to determine whether the
actions are autonomous. It is impor-
tant, however, not to rule out in
advance the possibility of a change
or even a conversion in basic values.
In some situations the health care
professional may have good reasons
to believe that if a patient is kept alive,
for example, by a particular treatment
that she is now refusing, she will
eventually ratify the coercive or decep
tive treatment on her behalf, perhaps
even thanking the professional. Such
a ratification does occur in some cases.
Can anticipation of future consent
justify present actions against a patients
express choices, in part on the grounds
that the present actions respect what
the person will be rather than what
she now is? My response is that actual
or predicted future consent is neither
necessary nor sufficient to justify
interventions against current choices.
At most, a patients probable future
consent may provide evidence that the
criteria for justified paternalistic inter-
ventions have been metg
Finally, respecting personal auton-
omy is complex because there are
several varieties of consent and
refusal. Although express consent (or
refusal) is the primary model, consent
(or refusal) may also be implicit, tacit,
or presumed. To take one example,
solid organ procurement in the U.S.
is structured around express consent
or donation, whether by the individ-
ual while alive or by the family after
the individuals death. Rut there is
also presumed consent in the dona-
tion of corneas in a dozen states.
Presumed donation is not necessarily
a breach of the principle of respect
for autonomy. I n some circumstan-
ces, silence or a failure to refuse
donation could appropriately be
construed as donation. For presumed
donation-perhaps better viewed as
tacit donation-to be autonomous
and valid, society needs to make sure
that the conditions of understanding
and voluntariness have been met.
Otherwise, the appeal to presumed
donation may only be expropriation.
I
Scope or Range of Respect for
Autonomy
I n explicating the principle of
respect for autonomy as limited, I
want to focus on its limited scope or
range, and on its limited weight or
strength. If these limits are not
recognized, it is too easy to dismiss
the principle as extending too far or
as outweighing or overriding too
much. Deflation of claims for and
about the principle of respect for
autonomy is essential to its
preservation.
Respect for persons who are auton-
omous may legitimately differ from
respect for persons who are not
autonomous. The presence, absence,
or degree of autonomy is a morally
relevant characteristic (though hardly
the only morally relevant character-
istic) in shaping our actions and
attitudes toward others. When people
are autonomous, respect for them
requires (or prohibits) certain actions
that may not be required (or pro-
hibited) in relation to nonautonom-
ous persons. Several principles may
establish minimum standards of
conduct, such as noninfliction of
harm in relation to all persons
whatever their degree of autonomy.
14
Hastings Center Report Januarg/Februay 1990
But what the principle of respect for
autonomy requires (and prohibits) in
relation to autonomous persons and
in relation to nonautonomous per-
sons will differ. Thus, Kant excluded
children and the insane from his
discussion of the principle of respect
for persons and Mill applied his
discussion of liberty only to those in
the maturity of their faculties.
Nevertheless, it is appropriate to
operate with a presumption in favor
of adults autonomy, unless and until
they are determined to be substan-
tially nonautonomous. Several factors
of autonomy are relevant; these
include incompetence, i.e., an inabil-
ity to perform certain tasks, lack of
understanding, and lack of voluntar-
iness (both internal and external).
When these signs of nonautonomy
occur, and people are at risk of harm
or loss of benefits to themselves,
interventions based on beneficence
can be justified, and they do not
violate the principle of respect for
autonomy even if the person refuses.
This is limited beneficence or limited
paternalism.O
However, the principle of respect
for autonomy can be overextended
in ways that are misleading and even
dangerous. One simple but risky
overextension is to refer to the
cadaveric sourceof organs for trans-
plantation as a donor even if he or
she never donated, perhaps
because the individual never had
autonomy or never chose to donate.
The donor is one who autonomously
decides to donate, whether an indi-
vidual while alive or a family member
after the individuals death. If the
decedent never made a decision to
donate while alive, the family is the
donor. A more troubling example can
be found in presumed (consent)
donation for corneas; as noted above,
it often appears to be a fiction for
expropriation.
Another troubling example is the
appeal to substituted judgment in
circumstances where it does not
plausibly apply. If a person has prev-
iously (and competently) expressed
preferences with sufficient clarity,
that persons autonomous preferen-
ces can and should be extended to
periods of lack of autonomy. How-
ever, for patients who have never
been autonomous or for previously
Respect for autonomy does not exhaust the moral life. Other princi-
ples are important, not only where autonomy reaches its limits. For
example, focusing narrowly on the principle of respect for autonomy
can foster indifference; thus principles of care and beneficence are
necessary. But without the limits set by the principle of respect for
autonomy, these other principles may support arrogant enforcement
of the good for others.
autonomous patients whose prior
preferences and values cannot be
reliably traced, it is more defensible
to rely on a best-interests standard,
based on nonmaleficence and benef-
icence, rather than on a substituted
judgment standard, based on auton-
omy. The standard of substituted
judgment should be rejected in such
situations as an illegitimate fiction.
A final point needs to be made
about scope or range. The principle
of autonomy has been criticized as
minimalist and perhaps even egoistic
in nature or at least in application
in our sociocultural context This
criticism focuses on a persons claim
to have his or her autonomy
respected rather than on a persons
obligation to respect the autonomy of
others. The principle of respect for
autonomy, however, involves correl-
ative rights and obligations. And it is
thus a principle of obligation, rather
than liberation from obligation. Here
again the confusion may stem in part
from the misleading language of
principle of autonomy, which
should be replaced by the principle
of respect for autonomy.
Even as a principle of obligation,
respect for autonomy does not
exhaust the moral life. Other prin-
ciples are important, not only where
autonomy reaches its limits. For
example, focusing narrowly on the
principle of respect for autonomy can
foster indifference; thus principles of
care and beneficence are necessary.
But without the limits set by the
principle of respect for autonomy,
these other principles may support
arrogant enforcement of the good
for others. Nevetheless, these and
other principles sometimes outweigh
15
or override the principle of respect
for personal autonomy.
Limits of Weight or Strength
The principle of respect for auton-
omy is more than a maxim. Yet it is
not absolutely binding and does not
outweigh all other principles at all
times. Two major alternatives remain.
It could be viewed as serially ordered,
taking absolute priority over some
other principles; or it could be viewed
as prima facie binding, competing
equally with other prima facie prin-
ciples in particular circumstances. I
take the latter approach. Even though
this avoids a priori rankings and is
thus case-oriented or situational, it is
different from some perspectives on
casuistry, because the logic of prima
facie principles dictates a procedure
of reasoning or justification for
infringements of principles in partic-
ular circumstances. For example, the
prima facie principle of respect for
autonomy can be overridden or
justifiably infringed when the follow-
ing conditions are satisfied Propor-
tionality-When in the circumstances
there are s t r qer competing princi-
ple(s); EEectiveness-when infring-
ing the principle of respect for
autonomy would probably protect the
competing principle(s); Last
Resort-when infringing the princi-
ple of respect for autonomy is nemary
to protect the competing principle(s);
Least Infringement-when the
infringement of the principle of
respect for autonomy is the least
intrusive or restrictive in the circumstan-
ces, consistent with protecting the
competing principle(s).12
In addition, wherever possible and
Hastings Center Report, Janua y/Februa y 1990
appropriate, we should explain and
justify the infringement of the prin-
ciple of respect for autonomy to those
agents whose autonomy has been
infringed.
The question of mandatory screen-
ing or testing for HIV infection
instructively illustrates the reasoning
required when moral values conflict
As the first public health crisis in an
era of firmly established civil rights
and liberties, AIDS poses important
questions about the place and signif-
icance of the principle of respect for
autonomy, especially in relation to the
community as well as to other indi-
viduals. The needs of the community
in public health may well override the
rights related to the principle of
respect for autonomy of some indi-
viduals under some circumstances to
reduce the spread of HIV infection.
Consider, for example, the principles
or rules of liberty, privacy, and
confidentiality. These may be derived
from the principle of respect for
autonomy, but even if they have
independent standing, they are
nevertheless closely related to the
principle of respect for autonomy, for
individuals may exercise or waive
their rights to liberty, privacy, and
confidentiality and thereby remove
the constraints on actions by others
in particular cases. But even when
individuals do not waivetheir rights,
their rights and their autonomous
choices regarding those rights may
sometimes be overridden.
Even in actions to protect the
community, it is important to staxt with
a presumption in favor of the prin-
ciple of respect for autonomy, as
expressed in liberty and privacy, and
then to determine whether that
presumption can be rebutted by
arguments for mandatory screening
or testing. Critics sometimes doubt
whether it is appropriate for the
community to have to bear the
burden of proof for overriding
respect for autonomy, but in view of
the communitys power and tendency
to abridge autonomy, along with the
importance of the principle of respect
for autonomy, this is not an inappro-
priate burden and it can sometimes
be met. For example, if weapply the
conditions identified above for over-
riding prima facie obligations, it
would be necessary to consider the
proportionality and effectiveness of
any proposed mandatory screening
or testing; the absence of an alter-
native; the least infringement of
autonomy and privacy (the least
restrictive and intrusive options)
consistent with achieving the end;
and finally, an explanation and
justification to those whose autonomy
and liberty are infringed on behalf
of a communal g00d.l~I n view of what
we now know about HIV and its
transmission, very few types of man-
datory screening and testing would
meet these conditions-donations of
blood, semen, and organs and per-
haps a few others.
This pattern of justification holds
in efforts to protect the community
or other individuals, including health
care professionals, within the com-
munity. Whatever the target, it is
important to recognize when the
principle of respect for autonomy-
and associated principles-are being
overridden, rather than camouflag-
ing the justification as one of respect
for autonomy. The wrong approach
appears in recent Virginia legislation
that appeals to deemed consent to
justify HIV testing and release of test
results in certain situations. The
legislation provides that
whenever any health careprovider, or any
person employed by or under the direc-
tion and control of a health careprovider,
is directly exposed to body fluids of a
patient in a manner which may, according
to then current guidelines of the Centers
for Disease Control, transmit human
immunodeficiency virus, the patient
whosebody fluids wereinvolved in the
exposureshall be deemed to have ment ed
to testing for infection with human
immunodeficiency virus. Such patient
shall also be deemed to have consented to
the rehue of such test results to the person
who was exposed In other than emer-
gency situations, it shall be the respon-
sibility of the health care provider to
inform patients of this provision prior to
providing themwithhealth care services
which create a risk of such exposure
(Virginia Code 32.1-45.1; emphasis
added).
The danger of both overextending
and overweighting the principle of
respect for autonomy is evident in this
move to deemed consent. It is an
inappropriate fiction to construe
testing and release of information as
based on the principle of respect for
autonomy in situations where individ-
uals did not consent and perhaps
even explicitly refused to consent.
Whatever the rationale for the Vir-
ginia legislation, it is better to face
directly the conflict between the
principle of respect for autonomy and
other principles rather than to
reinterpret the principle of respect for
autonomy by extending it to circum-
stances where it does not apply. Then
wecan address whether the principle
of respect for autonomy can be
outweighed by competing principles
in the circumstances.
The principle of respect for auton-
omy is very important in the firma-
ment of moral principles guiding
science, medicine, and health care.
However, it is not the only principle,
and it cannot be assigned unqualified
preeminence. A clear example of
overconcentration on the principle of
respect for autonomy and its impli-
cations can be seen in research
involving human subjects, where for
years the subjects voluntary,
informed consent tended to over-
shadow all other ethical issues. As a
consequence, there was neglect of
other important moral considerations
that must be met prior to soliciting
the potential subjects consent to
participate-e.g., research design,
probability of success, risk-benefit
ratio, and selection of subjects.* To
be sure, if researchers do not receive
the potential subjects voluntary,
informed consent, they may not enlist
that subject. However, the right of the
potential subject to refuse to partic-
ipate in research became for many
the only moral constraint worthy of
attention, even though this issue
should not be addressed until other
prior important ethical issues have
been resolved.
In addition, concentration on the
principle of respect for autonomy
invited inadequate reasons for reject-
ing or redirecting some research on
some populations. For example,
critics of research involving prisoners
tended to argue that the principle of
respect for autonomy cannot be met
in an inherently coercive environ-
ment. However, a more defensible
ethical criticism emerges from the
principle ofjustice-the unfair impo-
sition of the burdens of research on
16
Hastings Center Report Januay/Februay 1990
a captive and vulnerable population
many of whomhave already suffered
serious deprivations in the society.
Yes, we should go beyond the
principle of respect for autonomy-
in the sense of going beyond its
misconceptions and distortions and
in the sense of incorporating other
relevant moral principles. But going
beyond should not mean abandon-
ing. Despite its complexity in appli-
cation, despite its limits in scope or
range and in weight or strength, and
despite social changes, the principle
of respect for personal autonomy has
a critical role to play in biomedical
ethics in the 1990s. But that role
requires a sense of limits; we must
not overextend or overweight respect
for autonomy.
References
James F. Childress, Ensuring Care, Respect,
and Fairness for the Elderly, Hastings Center
Report 14:5 (1984), 27-31. For criticisms of
autonomy, see essays by Daniel Callahan,
Eric Cassell, and Robert Morison in the
same issue.
In the third edition of Primipler OfBimzdical
Ethics (New York Oxford University Press,
1989), Tom L Beauchamp and I reformulate
what we had earlier called the principle
of autonomy as the principle of respect
for autonomy.
See, for example, Gerald Dworkin, Auton-
omy and Behavior Control, Hastings Center
Report 6:l (1976), 23-28.
This formulation is influenced by Ruth R
Faden and TomL Beauchamp, A HistMy
and Theoly of lnfonned Consent (New York
Oxford University Press, 1986).
See, for example, Eric J. Cassell, Taking with
Patients, 2 vols. (Boston: MIT Press, 1985).
See James F. Childress, Who Should Decide?:
Paternulism in Health Cure (New York Oxford
University Press, 1982).
I Childress, Who Should Decide?, 22425. This
case was prepared by Gail Povar, MD.
Bxuce Miller, Autonomy and the Refusal
of LifeSaving Treatment, Hastings Center
Childress, Who Should Decide?.
Childress, Who Should M?.
See, for example, Daniel Callahan, Min-
imalist Ethics, Hmtings Center Report 11:5
(1981), 19-25.
For a somewhat different formulation, see
Beauchamp and Childress, Principles of
Biomedical Ethics, 3rd ed., 53.
See James F. Childress, An Ethical Frame-
work for Assessing Policies to Screen for
Antibodies to HN, AlDS and Public Policy
Jounzal2 (winter 1987), 2831.
l4 See, for example, James E Childress, Pri ori ti es
in Biomedical Ethics (Philadelphia: The
Westminster Press, 1981), 51-73.
Report 11~4 (1981), 22-28.
Fooling with
Mother Nature
by Willard Gaylin
T
I n 1816 Mary Godwin (Shelley to
be) was holidaying in the Swiss
mountains near Geneva, staying at
the Villa Diodati. It proved a wet
ungenial summer and incessant rain
often confined us for days to the
house. It was during this summer
holiday spent with Shelley and Byron
that she wrote her story of Dr.
Frankenstein. She was all of nineteen
at the time.
The story was intended to be a
diversion for the author and an
amusement for the poets. Yet the
lightly conceived Frankenstein; Or t h
Modern Prom&.eu.s was to ensure Mary
Shelleys immortality and was prob-
ably to have a greater impact on the
sensibilities of our time than the mon-
umental works of those two giants of
nineteenth century romantic poetry.
When Mary Shelley first published
her story, wewere at the beginning
of the modem scientific revolution.
The idea of one human being
fabricating another was pure meta-
phor. The feat was presumed impos-
sible, beyond human imagination, a
grotesque exaggeration. It was a
gothic tale, a device for the author
to express her philosophical concern
about the questing nature of the
human being and the potential
dangers inherent in this ambitious
poking, prodding, nervous, unsatis-
fied attempt to know everything, to
control everything, to confront the
forces of nature and to conquer it.
Wewere intended to identify with Dr.
Frankenstein. He was the nineteenth
W h d Gtylin, a psychiatrist, is president
of T h Hmtings Center. This paper is
adappd, with permission, porn Adam
and Eveand Pinocchio, forthcoming,
Kking Press, March 1990.
century man committing the classical
crime of a Greek poet of the fifth
century B.C., the crime of hubris-
overweaning pride.
By the end of the nineteenth
century, the scientist was more than
a rival to God; he wm God. Technol-
ogy had surpassed even its own
expectations. There was nothing it
would not eventually solve. Wewere
too arrogant even to recognize
arrogance. We did not have to fear
God for we had replaced Him. Up
to that point the whole of history
seemed to have contrived to serve the
purposes and glorify the name of
Homo sajnms.
Now as we approach the end of
the twentieth century wefind that the
myth of Frankenstein has become an
everyday reality. With the miracle that
is modem surgery weuse patches and
parts, manufactured and real, bor-
rowed from ourselves, other living
human beings, or cadavers, and we
stitch them together with sutures of
nylon or pins and staples of stainless
steel. The development of such an
extraordinary technology that gives
ambulation to the lame and life to
the dying is a glory to our species.
The fabrication of a human being
is no longer mere metaphor or
literary device. It is an everyday fact
in the operating rooms across the
country. The inconceivable has
become conceivable. Dr. Franken-
stein is at work in every major city
of the modem world. Wehonor, we
revere, werespect and need him. We
wish him well and urge him to go
further. An artificial heart, a brain
transplant, go further-an artificial
placenta; go further.
These are achievements from
which weshould take pride. Why then
does the Frankenstein myth still have
17