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205215Original articleAutonomy and Autonomy Competencies Kim Atkins

Original article
Autonomy and autonomy competencies: a practical and
relational approach
Kim Atkins RGN BA PhD
School of Philosophy, University of Tasmania, Launceston, Tas., Australia

Abstract This essay will address a general philosophical concern about autonomy,
namely, that a conception of autonomy focused on freedom of the will
alone is inadequate, once we consider the effects of oppressive forms
of socialization on individuals’ formation of choices. In response to this
problem, I will present a brief overview of Diana Meyers’s account of
autonomy as relational and practical. On this view, autonomy consists
in a set of socially acquired practical competencies in self-discovery, self-
definition, self-knowledge, and self-direction. This account provides a
distinction between choices that express unreflectively internalized
social norms and those that are the result of a critical ‘self-reading’. I
conclude that this practical conception of autonomy makes much higher
demands upon nurses (and patients) than has previously been thought.
In fact, if nurses are to be expected to genuinely promote autonomy,
they are going to need specific training in counselling-type communica-
tion skills.

Keywords: autonomy, practical competencies, free will, socialization,

self-knowledge, self-conception, self-direction, communication.

upon a liberal conception of autonomy as the

The concept of autonomy
informed and uncoerced choice of fully rational
Autonomy is a fundamental concept in ethics gener- agents employing their individual free will (Rous-
ally and in healthcare ethics in particular. The legis- seau, 1972; Forsyth & Keens-Soper, 1996; Staunton &
lative framework of nursing practice in Australia, the Whyburn, 1997). The practical shortcomings of this
UK, Western Europe, and North America is premised traditional conception of the autonomous individual
are well known. For example, with the onset of
dementia, a person may meet the criteria for rational
Correspondence: Dr Kim Atkins, Lecturer, School of agency at some moments but not others. Another
Philosophy, University of Tasmania, Locked Bag 1-340F, frequently encountered difficulty lies in determining
Launceston, Tas. 7250, Australia. Tel.: +61 36324 3522; fax: whether or not a young person – a ‘minor’ in the eyes
+61 36324 3652; e-mail: kim.atkins@utas.edu.au of the law – meets the criteria for autonomy. A teen-
Original article

© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215 205
206 Kim Atkins
age girl, for example, may be considered insufficiently
physiologically and rationally developed to consent
to sex, contraception, or surgery, but nevertheless
able to take responsibility for mothering a child and
consenting to surgical treatment for that child. This
essay will address a more general and pervasive philo-
sophical concern about autonomy conceived as free-
dom of choice where such freedom consists in the
exercise of an abstract free will. The concern is that
such a conception of autonomy is inadequate, once
we consider the effects of oppressive forms of social-
ization on individuals’ formation of choices. The
implication of this view is that the political organiza-
tion of liberal societies and the forms of socialization
those societies entail need to be overhauled before
autonomy can become a widespread practical reality.
In response to this problem, I will present a brief
overview of an alternative account of autonomy
based on Diana Meyers’s (1989) view of autonomy as
relational and practical. On this view, autonomy con-
sists in a set of socially acquired practical competen-
cies in self-discovery, self-definition, self-knowledge,
and self-direction. This account preserves the conven-
tional intuition that personal choice is fundamental
to autonomy and that autonomy is fundamental to
ethical life, while providing a critical distinction
between choices that express the internalization of
oppressive social forces and those that express one’s
genuinely reflective considerations. I conclude by
noting that conceiving of autonomy in terms of prac-
tical competencies rather than an abstract free will
makes much higher demands upon nurses than has
previously been thought. In fact, to effectively pro-
mote autonomy, nurses need specialized counselling
and communication skills. Nevertheless, this ap-
proach opens new possibilities for nurses to identify
processes that facilitate autonomy and to address
those that obstruct it. For example, a nurse who can
understand how a patient’s personal choices can be
underpinned by unreflective conventional gender or
age roles can, in dialogue with the patient, provide
the opportunity for the patient to express uncon-
ventional and genuinely felt aspects of her self-
conception. Acknowledging aspects of an individual’s
self-understanding that are otherwise socially deval-
ued or ignored can give those aspects a legitimacy
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
and, so, enrich that individual’s self-knowledge, lead-
ing to life-decisions that more accurately reflect an
individual’s identity and ‘authentic’ self.
The mainstream philosophical view of autonomy is
perhaps best known and articulated in the work of
theorists such as Gerald Dworkin, Gary Watson, and
Harry Frankfurt, who share in a common liberal her-
itage (Watson, 1975; Young, 1986; Dworkin, 1990).
The case for autonomy, as it is generally understood
today, was made by John Stuart Mill (1975) in 1859.
Mill believed in the concept of a common humanity:
all adult, rational individuals are to be regarded as
moral and political equals. On the basis of their equal
rationality, all such persons should be free (i.e. unco-
erced by any individual or the state) to decide for
himself or herself how to live and what to do (even it
causes that individual harm), and the only limit to this
personal liberty should be that its exercise not inter-
fere with another person’s identical liberty. At a polit-
ical level, a society should be regulated by law to
disallow only those activities that interfere with our
equal rights to personal liberty. Autonomy, then, is
the right to determine for oneself one’s interests,
goals and values, and one’s own conception of a good
life free from unwarranted interference.
Underpinning this conception of autonomy is a cer-
tain conception of persons. It is the view that persons
are radically individualistic. By ‘radically individual-
istic’, I mean that the determination of one’s beliefs,
values, tastes, aspirations, and actions is an activity of
one’s individual free and rational will. In virtue of the
individuality of one’s free will, each person is a ‘self-
sovereign’, answerable only to the principle of respect
for others’ identical freedom (our common human-
ity), expressed in the principle of non-interference.
Individuals are free to give each other advice if they
believe each other to be acting in error, but the only
legitimate reason for interference in another’s actions
is if those actions present clear and immediate harm
to another person’s equal liberty (Feinberg, 1973, pp.
36–54). How the principle of non-interference pans
out in real life is a matter of debate among liberal
theorists. Libertarians at the extreme end of the spec-
trum argue that the principle not only entails the right
to be left alone but also removes any obligation to
help any other person – adult or child – under any

circumstances, even where helping would present
no inconvenience (Sterba, 1998, pp. 237–244;
Grunebaum, 2003, pp. 110–117). At the other end of
the spectrum, liberals argue that although we should
not meddle with individuals’ lives, we have an obliga-
tion to make sure that society is organized in such a
way as to maximize individuals’ choices fairly, for
example, such that a change in the distribution of
wealth must ensure that the worst off benefit (Rawls,
1971). However, regardless of where one is placed
along the spectrum of views, it remains a core princi-
ple of liberalism that autonomy is the exercise of
individual self-sovereignty and that one’s free will is,
if you like, the central executive.
This remains the view that currently dominates the
legal, regulatory framework of healthcare practices
in Western nations and, for that reason, dominates
actual clinical practice. This is why we are taught that
informed consent requires disclosure (that the
patient be fully informed), comprehension (that the
patient be fully rational), and voluntariness (that
the patient be free from coercion). The nurse’s role
in promoting autonomy is conceived directly in rela-
tion to these requirements: it is to provide informa-
tion, advocate for the patient’s express or implied
wishes, and eliminate as far as possible, external
influences on the patient’s deliberative processes.
The relational theory of autonomy
Diana Meyers (1989) argues that one of the features
of the liberal tradition of autonomy, premised as it is
on the notion of individual free will, is that autonomy
has come to be characterized in opposition to social-
ization. In other words, the individual (in the form of
one’s abstract free will) has been conceptualized as
the central executive and arbiter of choice, the integ-
rity of which is secured by resisting the (potentially)
invasive power of social forces. Here, autonomy
understood as personal liberty must be secured
against the pervasive effects of state power, hence
Mill’s (1975, p. 15) insistence that the legitimacy of
state power consists solely in protecting individuals
from interference. This position does not mean that
social relations are to be avoided, but rather, that part
of what it means to be autonomous is to enjoy pro-
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
Autonomy and Autonomy Competencies 207
ductive and enabling relations with others rather than
being subjected to the deleterious effects of power,
whether exercised by an individual, group, or the
state.
While it is important to note that Mill and others,
more recent theorists, recognize that social relations
play some role in the exercise of autonomy; neverthe-
less, social relations tend to be regarded as causal
conditions that promote radical self-sufficiency,
rather than being regarded as intrinsic to autonomy.
Furthermore, mainstream accounts do not sufficiently
distinguish between social relations that promote
autonomy and those that impede its development
(Friedman, 1997, pp. 40–61). Meyers argues that in
order to make that kind of distinction, the neutrality
of the ‘free will’ must be replaced by a critical con-
ception of autonomy that can articulate the way in
which gendered and other socialized forms of identity
impact upon one’s deliberative capacities and self-
conception. In short, Meyers’s criticism is that,
despite apparent concessions to the social context,
traditional conceptions of autonomy, insofar as they
are premised upon an abstract free will, continue to
treat social forces as illegitimately constraining
choices. In contrast to the metaphysically influenced
philosophies of ‘free will’, Meyers proposes a practi-
cal and ‘relational’ model of autonomy that consists
in a set of socially acquired competencies in critical
skills of self-knowledge, communication, and deliber-
ation. In her practical account of autonomy compe-
tencies, Meyers has provided at least the beginnings
of a philosophical framework in which distinctions
between social relations that promote autonomy and
those that impede its development can be made.
The relational view of autonomy claims that when
we exercise personal autonomy, we employ specific
cognitive and practical capacities that are not merely
private attributes of a free will, but rather, capacities
that can only be acquired and exercised in relations
with other people. In Meyers’ view, because auton-
omy consists in socially acquired competencies, dif-
ferent forms of socialization may facilitate or obstruct
the development of autonomy, and so, the question
of whether or not an individual’s choices are free
needs to be determined by reference to the social
context in which that person’s beliefs, values, desires,
208 Kim Atkins
interests, and importantly, identity are formed. In this
regard, it is important to distinguish personal auton-
omy from political autonomy. Although a person may
well have political autonomy in virtue of possessing
rights to vote, to privacy, to free assembly and reli-
gious worship etc., these do not guarantee personal
autonomy understood as the capacity for critical self-
reflection, self-definition, self-discovery, and self-
knowledge (Mackenzie, 2003).
Meyers argues against mainstream theorists – such
as Gary Watson, Robert Young, and Gerald Dworkin
– who conceive of autonomy as a variety of free will
and who, in doing so, effectively place autonomy and
socialization in opposition to each other. For these
theorists, the exercise of autonomy consists in reflect-
ing upon and acting upon what you really want to do
or be in order to free yourself from the restrictive
effects of beliefs and attitudes that you have been
socialized or indoctrinated to hold. On this view, the
normative force of socialization acts as a kind of
causal determinism with respect to our identities, and
so, renders us heteronomous rather than autono-
mous. For example, Sam enjoys watching extremely
violent movies, but this preference of his attracts fre-
quent criticism from some of his friends and family.
He reflects and finds that, despite the feelings of quilt
and shame that his friends’ criticisms evoke in him,
he nevertheless enjoys these films and wants to watch
them. On the mainstream view, if he were to bow to
social pressure and give up these movies, his personal
liberty would be unjustifiably constrained.
Consider this perhaps more complex and troubling
scenario: Jane is an 80-year-old Christian in the ter-
minal stages of cancer. She is cared for by her daugh-
ter in her daughter’s home. She reflects that she has
had a rich and happy life and that the little time left
to live will be painful or lost in a drug-induced leth-
argy. She also reflects that she is a considerable bur-
den on her daughter, who is elderly herself and has
little money or other resources to spare. Jane opts for
euthanasia, even though she knows that euthanasia
has no support among her family and community. The
challenge here for the ‘free will’ view of autonomy is
to distinguish Jane’s genuine choice from a set of
merely socialized beliefs. However, it seems that any
of her alternatives can be explicable in terms of
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
socialization. For example, is her rejection of the
Christian prohibition on euthanasia a rejection of
that socialization, or is her choice of euthanasia
merely an expression of another set of socialized val-
ues (e.g. the belief that sickly old people are an
increasing burden on the younger generation)? How
does the free will find its way through the maze of
socialized traits to the neutral point of view from
which ‘real’ choice can issue?
In addressing this kind of problem, Meyers makes
the point that, in the effort to avoid succumbing to
choices that merely express a socialized set of beliefs
or values, one would have to make explicit the
entirety of one’s conscious and unconscious life. Then
one would need to be able to distinguish socialized
thought from non-socialized thought. The key to suc-
cess in this kind of endeavour would be to accurately
deploy criteria for choices that are non-socialized
from those which are socialized (Meyers, 1989, p. 29).
Given the gargantuan practical, logical, and philo-
sophical problems involved in making all unconscious
drives, propensities, and dispositions conscious, the
prospect for success here seems rather low, and so, we
have good reason to reject this view.
Meyers next turns to a different way that some
theorists argue in defence of a free will model of
autonomy. A core idea in all theories of autonomy
(including Meyers’s) is the idea that autonomy
involves self-definition: the deliberate effort to nur-
ture a particular kind of will or personality in oneself.
On this view, the self shapes itself by reflecting upon
and endorsing some of its traits while repudiating
others [an approach exemplified in the work of Harry
Frankfurt (1971)]. To illustrate, Jack acts autono-
mously by examining his character and making a
commitment to base his actions on character
strengths such as his enjoyment of physical labour
and interest in people of different ethnicity, while
making a sincere effort to avoid indulging in his love
of gambling and a tendency to jealousy. While the
idea of self-definition is indeed plausible and consis-
tent with Meyers’s own account, she cautions that
Frankfurt’s account of freedom of the will may not,
in fact, be compatible with autonomy. To see why, we
first need to examine Frankfurt’s view.
Frankfurt writes:

It seems to me both natural and useful to construe the
question of whether a person’s will is free in close analogy
to the question of whether an agent enjoys freedom of
action. Now, freedom of action is (roughly, at least) the
freedom to do what one wants to do. Analogously, then, the
statement that a person enjoys freedom of the will means
(also roughly) that he is free to want what he wants to want.
More precisely, it means that he is free to will what he wants
to will, or to have the will he wants. . . .
It is securing the conformity of his will to his second-order
volitions, then, that a person exercises freedom of the will.
(Frankfurt, 1971, p. 15)
In other words, we exercise autonomy not in
respect of our ‘first-order’ desires i.e. not in respect
of choosing between various objects but, rather, with
respect to a reflective, or ‘second-order’ desire that is
expressed as the desire to have certain desires. When
we reflect upon and evaluate our first-order desires,
selecting and endorsing those desires we want to
motivate us, we develop second-order desires. When
second-order desires operate as reasons for our
actions, they become ‘second-order volitions’. For
Frankfurt, freedom of the will operates at this second
level where we determine for ourselves the kind of
things that we will take as reasons for acting. In this
way, our actions are autonomous because they are
driven by second-order volitions. One becomes an
autonomous agent when one structures one’s will in
this way.
It is true that, for Frankfurt, the process whereby
one comes to endorse certain values and beliefs is
driven by emotions and desires; it is a process driven
by what one cares about. Although this gives a nor-
mative dimension to autonomy, the freedom of the
will – or autonomy – is not itself a social phenome-
non; it is an abstract reflective power exercised upon
the contingent cognitive and emotional states that
manifest in different individuals. The process of self-
selection that constitutes the formation of second-
order volitions is the work of an agency that is
logically prior to the socialized traits from which it
selects. This can be seen in Frankfurt’s (1971, p. 13)
analysis of addiction, where he distinguishes actions
in which the agent participates (through reflective
endorsement), from actions in which the agent is a
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
Autonomy and Autonomy Competencies 209
kind of passive bystander, moved by ‘a force other
than his own’. The difficulty with this view is that it is
not at grips with the idea that the formation of one’s
will could be an expression of a self-conception that
is the product of coercive social forces. For Frankfurt,
one’s autonomy is realized just so long as one’s
choices are a result of second-order volitions. How-
ever, as Francois Schroeter (2004) has argued
recently, because Frankfurt’s theory is desire-based,
the idea of second-order volition is compatible with
the idea that the desire motivating an action is simply
one’s favourite. Unfortunately, this is also compatible
with the situation where my ‘favourite’ desires are
themselves a product of oppressive socialization, and
so, Frankfurt’s volitional account lacks the means to
distinguish oppressive from enabling effects of social
relations.
Despite Frankfurt’s attention to the normative
basis of one’s desires, the concept of self-selection
presupposes that the free will is the work of an agency
distinct from its socialized traits. Meyers argues that
this leads to the difficulty that if we suppose such a
distinction between an individual self and all of that
individual’s socialized traits, we are left with an indi-
vidual who is constituted by whatever the remaining
‘free’ non-socialized self turns out to define them as.
If it is anything at all, such a self is not free in the
required sense. As Meyers notes,
Unless we suppose that the selecting self is already a free
agent deploying standards independent of socialisation in
making its choices, this mode of self-definition will not
escape the self’s immersion in the social world . . .
But self-definition becomes superfluous, if not impossible,
once we grant the supposition that the selecting self is a free
agent. (Meyers, 1989, p. 45)
The problem here is that the free will view of
autonomy leaves us with two equally unacceptable
options: either self-definition is an effect of a consti-
tutive rule of the true self, in which case there is
nothing free about it (it just is what it is); or the true
self is unconstrained by rules in which case a person’s
choices occur at the whim of this unruly and capri-
cious being. Lacking rules, such a self is just as likely
to pursue incompatible projects as pursue a coherent
life.
210 Kim Atkins
As a consequence of these considerations, Meyers
concludes that free will is the wrong orientation to
autonomy. Rather, she argues for a reorientation of
autonomy away from a matter of desires competing
to be reasons for action, to the issue of the integration
of the self as a condition for agency – or, as she puts
it, the question of how to live in harmony with one’s
‘authentic self’ (Meyers, 1989, p. 40). The integration
of the self is not simply the inner work of a reflective
mind ordering its desires, but rather, a complex pro-
cess that necessitates relations with other people. This
means that if autonomy in general consists in being
able to do what you really want to do, then socializa-
tion actually needs to be adjusted to promote the
‘harmonious’ development of the individual. Here,
Meyers turns her focus to the way positive processes
of socialization mediate individual selves to produce
coherent and competent moral agents. Her theory
highlights the fact that what has been regarded as free
will is actually a complex set of socially acquired cog-
nitive, communicative, and practical skills. These
skills she designates as autonomy competencies.
Autonomy, on this view, consists in living in har-
mony with one’s authentic self. However, Meyers is
very clear that the authentic self is not any kind of
transcendental ego or non-bodily essence. The authen-
tic self is the ‘who’ or identity that comes into existence
through the acquisition and exercise of autonomy
competencies – competencies in self-discovery, self-
knowledge, self-definition, and self-direction. On this
view, there is no separate inner ‘self’ that has its own
nature or natural character. There is only
. . . the repertory of skills constitutive of autonomy along
with the collocation of attributes that emerge with the suc-
cessful exercise of those skills. (Meyers, 1989, p. 92)
Authentic selves, then, can take many shapes and
forms in many different cultural settings. There is not
one thing that it is to be authentic; there is simply the
realization, in an individual’s identity, of the ‘reper-
tory of skills constitutive of autonomy’, along with
culturally specific attributes through which those
skills are expressed.
Meyers’s focus on the importance of internal
coherence for a harmonious existence leads her to
argue that the acquisition of autonomy competencies
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
requires that one have a life plan. (This long-term
view of the self is another significant difference from
conventional views of autonomy where long-term
planning is not a requirement for either rational
deliberation or free will.) While this requirement
seems a little strong, as probably few of us plan out
our whole lives; nevertheless, autonomy competen-
cies require that one have some conception of the
kind of life one wants to lead. As Meyers notes, a life
plan is the response to the question of the qualities
one wants to have; the relationships one wants to be
involved in; and the interests and goals one wants for
oneself. It ‘affords individuals the opportunity to ask
themselves what they really want and to puzzle out
an answer’ (Meyers, 1989, p. 50). The authentic self is
the self realized through the realization of a life plan:
one becomes the kind of person one wants to be by
acquiring the desired qualities, talents, interests, and
relationships that are set out in the life plan. A life
plan is both episodic and programmatic. It is episodic
insofar as it is short-term i.e. one confronts a situation
and asks what one should and really wants to do and
then acts in accordance with that. It is programmatic
insofar it takes a long-term view i.e. one asks ‘how do
I want to live my life?’ Living according to a long-
term plan also allows spontaneous autonomous acts
because one does not have to consciously deliberate
about every single episode in one’s life.
Meyers argues that in order to realize a life plan –
i.e. in order to realize the kind of life one wants to be
living – we need certain kinds of skills in making
decisions about our lives. Specifically (Meyers, 1989,
p. 52):
• One must be disposed to consult oneself
• One must be equipped to consult oneself
• One must be able to ask oneself ‘what do I really
want/need/care, etc.’
• One must be able to act upon the answer
• One must be able to correct oneself when the
answer is wrong
• One must be able to reconcile conflicting wants/
needs
This leads Meyers to identify a further require-
ment. These skills require an integrated personality.
In order to knowingly self-direct, one needs a mini-

mal understanding of how one’s motives, values,
beliefs, emotional dispositions, desires, and foibles
can be related together and how they might influence
one’s choices and attitudes. This is a basic require-
ment for comprehending and negotiating one’s needs,
wants, and responsibilities in the many different cir-
cumstances one faces in life. Meyers’s (1989, p. 70)
conception of an integrated personality is one com-
posed of ‘characterological strands’ which are reflec-
tive flexible networks of attributes, desires, abilities
etc. This dynamic structure allows an individual to
reflect upon and elicit a range of feelings, attitudes,
beliefs, and judgements about herself in different sit-
uations, and so, by paying attention to these patterns
of responses, acquire self-knowledge. In short, one
without a minimally integrated personality cannot
ask oneself, nor answer the question of, which quali-
ties one wants to have; the relationships one wants to
be involved in; and the interests and goals one wants
for oneself. In other words, one cannot act on the
basis of reasons that are genuinely one’s own.
Deliberation over choices involves a kind of self-
reading. Self-reading is a skill in taking notice of our
responses and mental states and being able to explain
their origins to ourselves (Meyers, 1989, p. 79). We
need to be able to reliably self-read because we can
be moved by transient and irrational feelings, for
example, of guilt or shame, which can be powerful
enough to undermine one’s self-conception and life
plan if left unchecked.
The way to ensure that self-reading produces self-
knowledge, argues Meyers, is to move beyond
introspection to consider the light that others’ inter-
pretations of our behaviour throw on our own
explanations. This is a crucial aspect of Meyers’s
account. It is only through open, honest, and con-
structive communications with others – i.e. by expos-
ing our inner thoughts and feelings – that our
subjective reflections about ourselves take on an
objective and practical reality and significance.
Clearly, one needs more than a single ‘second opin-
ion’ as it were; one needs to belong to a community
of rational and benevolent individuals who are able
to provide a consistent and plausible account of one-
self. It is precisely because our self-conceptions are
mediated through our relations with others’ that
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
Autonomy and Autonomy Competencies 211
social relations can be both oppressive and liberating
(Benson, 2000, pp. 72–93).
The importance of others’ interpretations of our
self-explanations becomes clearer when Meyers
points out a number of well-documented psychologi-
cal phenomena of irrationality that affect how we
interpret ourselves. These irrationalities are peculiar
psychological processes that can lead us to misunder-
stand our own responses, and so, cause us to form
incorrect conclusions about the kind of persons we
are. These irrationalities are not strategies deliber-
ately and reflectively employed by any individual,
but, rather, unconscious and normal functional flaws
in our everyday thinking. One such irrationality is
known as the ‘availability heuristic’. This is a flawed
form of inference whereby we tend to conclude that
those things that we bring to mind more easily are
more likely to be the case. The availability heuristic
shapes people’s judgements about the frequency of a class
or the probability of an event by leading them to suppose
that instances which are easier to recall or imagine are more
likely to be the case. (Meyers, 1989, p. 173)
This is the kind of mechanism behind, for example,
the tendency to jump to conclusions. For example, as
a result of many years of oncology nursing, whenever
Jane notices blemishes on a person’s face, she
becomes concerned that the person may be develop-
ing a carcinoma. This is despite her knowing that
extremely few skin blemishes are carcinogenic.
Of course, one’s sense of the likelihood of an event
maybe the result of familiarity with the object (as in
the case above), or of having a particularly vivid
memory, and quite unrelated to the actual frequency
of the event. This is significant when it comes to
autonomy competencies and, specifically, com-
petency in self-discovery, which informs the self-
conception that underpins one’s choices. The
availability heuristic can reinforce those attributes of
oneself that are apt to stand out, and these are fre-
quently attributes that have a high social currency:
attributes that are represented particularly vividly or
which are easier to recall. Thus, in any particular sit-
uation, one is apt to interpret one’s responses to a
situation (or, to put it another way, self-read) as
instances of socially valued conventional attributes.
212 Kim Atkins
As a result, individuals tend to form conventional
self-portraits rather than portraits that may accu-
rately reflects how one actually feels about oneself
and one’s life. This is sadly well illustrated in the many
cases of young women who interpret their feelings of
dissatisfaction in their personal relationships as orig-
inating in inadequacies of their bodies and intellec-
tual capacities. Instead of reading their self-
referential responses as the effect of being arbitrarily
devalued, these women self-read in terms of conven-
tional norms of feminine beauty. By interfering with
processes of self-reading and self-definition, this irra-
tionality impedes the ability to authentically self-
direct and to realize a genuinely autonomous vision
of interpersonal relations.
Another psychological irrationality that Meyers
identifies as a common way in which autonomy can
fall foul of conventionality and lead to failure in self-
knowledge is by the effect that our prior theoretical
commitments have on the way we assimilate subse-
quent evidence. When a person has established a
well-defined self-concept, it is quite easy for that per-
son to recall behavioural evidence that supports that
self-concept but more difficult to recall behavioural
evidence that contradicts it. For example, a person
can genuinely believe that he is very generous, per-
haps as a result of earlier life experiences, despite the
fact that he steadfastly avoids buying raffle tickets or
donating money to charities, and rarely lends a hand
to anybody. As a result of his prior theoretical com-
mitments, he systematically fails to see his behaviour
as selfish or parsimonious, and so, fails in his self-
knowledge.
Meyers argues that the corrective to mistaken self-
conceptions and the path to competence in self-
reading is the critical involvement of other people –
people, in conversation with whom we test out our
theories and beliefs about ourselves, learn things
about ourselves and are forced to confront things
about ourselves. In short, it is through positive social-
ization, through respectful, fair, and constructive
communication in which we are recognized as worthy
agents of our own actions and the originators of our
specific reasons for acting that we can come to realize
our autonomy. Of course, the helpfulness of other
people depends upon their own critical capacities,
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
communicative skills, and values such as honesty,
integrity, and courage. Nevertheless, without this kind
of positive socialization, autonomy competency sim-
ply cannot be acquired because our identities will
succumb to forces of conventionality (Habermas,
1999).
Autonomy, on Meyers’s account, is a rarer beast
than commonly believed – not because individuals
are lazy in exercising their free will, but rather
because social and psychological forces have a pow-
erful combined effect in producing unreflective and
conventional self-conceptions against which the so-
called ‘free will’ is powerless. In a political context in
which justice, recognition, and the power to achieve
these remain distant ideals for many people, the goal
of promoting autonomy depends upon the develop-
ment of social processes which value and promote
critical self-reading and give rise to genuinely self-
knowing, self-trusting, self-directing, and ‘authentic’
selves. Clearly then, healthcare workers who claim to
promote autonomy need to be the kind of people who
can assist a patient to negotiate these powerful social
and psychological forces. In short, they need to be
skilled in facilitating critical and creative self-reading.
Applying autonomy
competency theory
Given this account of autonomy, in what ways can
nurses promote patient autonomy? Simply providing
information about options is not going to be enough.
Neither can there be some simple recipe or formula
that will ‘do the trick’, given the complexity of the
interrelation between the personal and the political
in the constitution of a person’s self-conception and
autonomy competencies. Recall that autonomy com-
petencies concern those skills deployed in determin-
ing one’s life as authentic. That is, it concerns the skills
required to integrate the self that one wants to be
with the self that one currently is. This is achieved by
posing and responding to such questions as the qual-
ities one wants to have; the relationships one wants
to be involved in; and the interests and goals one
wants for oneself. As I have noted earlier, this activity
requires the emotional, linguistic, cognitive, and com-
municative competencies which make possible the

ability to consult oneself; the ability to scrutinize
one’s beliefs, values, and character traits; the ability
to evaluate and prioritize those values and traits; the
ability to act upon those evaluations; and the ability
to correct oneself.
It may well be that in many situations there is little
if anything a nurse can do to promote autonomy.
Meyers’s account teaches us that, at the very least,
nurses cannot rest satisfied that they have respected
autonomy simply by providing medico-legal informa-
tion or obtaining a signature, although these are
important. Patients do not necessarily need more
choices; they need to make choices that are, as Mey-
ers puts it, in harmony with their authentic selves.
Respecting autonomy in the healthcare context
means facilitating the exercise of autonomous deci-
sion making (Dodds, 2000, pp. 213–235). In a society
in which ludicrously distorted visions of masculinity,
femininity, sexuality, ageing, and ability are con-
stantly imposed onto our self-conceptions, respecting
and promoting autonomy involves high-level
demands upon the skills of both patients and nurses.
Nurses need to be able to help patients to self-read
i.e. to critically reflect upon and understand their own
deliberative processes and self-conceptions that
underlie and motivate their choices. This is, in
essence, the difficult task of enabling patient literacy.
‘Patient literacy’ just means the ability of patients to
adequately self-read in the frequently ‘hot house’
environment of a hospital or clinic. Promoting patient
literacy requires that the nurse employ critical insight,
empathy, high-level conceptual and communicative
skills, and is able to nurture the patient’s insight by
facilitating structured and meaningful conceptual and
emotional self-expression (Nelson, 1997). This can be
achieved through careful dialogue in which the nurse
helps the patient, first, find the words and descriptions
needed to articulate beliefs, emotions, desires, and
values; second, helps the patient examine, evaluate,
and prioritize those phenomena; and finally, helps the
patient bring her beliefs, emotions, desires, and values
etc. together into a point of view. In facilitating this
process, the patient’s attention may be drawn to
recurrent but unexamined concepts and themes in
her self-conception; inconsistent patterns of reason-
ing and valuing; contradictions; or obvious omissions
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
Autonomy and Autonomy Competencies 213
in her account of herself and her hopes and values.
The nurse does this, not in order to force the patient
to be ‘truthful’, but in order to provide the occasion
for the patient to reflect upon and evaluate her
choices in the light of her beliefs, emotions, desires,
and values, and to form a narrative in which she can
identify herself and what is important to her.
To promote autonomy competencies, the nurse
needs insight into his own character, motives, and
dispositions, and needs to be acquainted with the
complex and sometimes ambivalent range and
dynamic interactivity of human emotions and ideas.
For example, the nurse needs to understand that the
patient may respond to aspects of himself of which he
is unaware. For this reason, a nurse needs to have a
good level of self-knowledge and be open to others’
interpretations of oneself. Acquaintance with the
complexities and diversity of human emotions can
occur either through personal experience, education,
or through exposure to the instructive examples of
literature (Nussbaum, 1986). Without a sufficient
degree of self-literacy, the nurse will not be able to
comprehend the way in which specific experiences,
relationships, and ideas can affect a person’s self-con-
ception and perspective of the world, and thereby,
affect that person’s choices and decisions. At the very
least, however, nurses can refrain from lapsing into
patronizing reassurances, platitudes, or clichés that
can interfere with patients’ spontaneous self-
expressions and narrative development.
It might be useful to consider a fictional case. Sue
is a young woman in a newly formed relationship who
has an extremely strong family history of breast can-
cer. She has been admitted for screening and was
subsequently offered the option of bilateral mastec-
tomy as a preventative strategy. Although this is a
rather dramatic example, the principles are the same
for any case where what is being consented is of sig-
nificance to the person consenting. This particular
example deliberately foregrounds the emotional, aes-
thetic, social, and interpersonal pressures that form
the horizon of each person’s life. By calling them
‘pressures’, I am drawing attention to the influential
role these aspects of life play in situations of consent.
They each provide a different perspective from which
one can consider the implications of one’s options,
214 Kim Atkins
but they can be, and are frequently, in some conflict
with one another.
Promoting patient autonomy in such a situation
requires that one provide assistance for Sue to nego-
tiate these conflicts in order to integrate the person
she wants to be (i.e. the desires, values, and actions
for which she wishes to be responsible), with those
desires, values, and beliefs she finds herself with cur-
rently. Doing this involves engaging in a dialogue in
which the nurse draws attention to different possible
influences informing Sue’s perspective at any time.
For example, Sue, at times, rejects surgery because
she is concerned that the loss of physical attractive-
ness (an aesthetic social value) will destroy her per-
sonal relationship. At other times, she wants surgery
to ensure the continuation of her life and the realiza-
tion of her professional ambitions (an emotional and
existential value). The nurse can put strategic
comments to Sue to highlight these influences and to
provoke the question of what Sue really wants in her
self-conception, for example: ‘When you talk about
how important your work is to you, or how much you
love hiking, or how supportive and fun your friends
are, I don’t hear you worrying about what people
think of your breasts.’
Clearly, this kind of dialogue requires highly devel-
oped intra-personal and interpersonal skills, a trust-
ing relationship and sensitivity in judging when and
with whom it is appropriate to initiate a self-reading
process. These are skills that require special training
and experience. Of course, some patients do not wel-
come the opportunity for self-examination, and it
may be that in some situations nothing can be done
to promote autonomy. Indeed, it seems likely that
many situations that have traditionally been regarded
as respecting autonomy do not in fact do this. This is
because the notion of the voluntariness of consent is
rendered problematic when we consider the effects
of socialization on the ways in which we exercise
choice. An obvious example of such a problematic
case is the use of cosmetic surgery to bring an indi-
vidual’s appearance closer to a socially valued ideal
of beauty. A more extreme example is the case of a
man who chooses euthanasia over palliative care
because he regards himself as an unreasonable bur-
den on his family as he is no longer the breadwinner.
© 2006 The author. Journal compilation © 2006 Blackwell Publishing Ltd Nursing Philosophy, 7, pp. 205–215
What makes these choices troubling is the sense that
underlying them are unjustifiable self-conceptions –
conceptions of one as unworthy or inadequate. From
the point of view of traditional liberal theory, we do
not have a way in to legitimately challenge such self-
conceptions on the basis that they are the product of
oppressive socialization because those theories do
not provide criteria for distinguishing coercive from
enabling socialization in the formation of one’s iden-
tity and values. Insofar as an individual is rationally
competent, we are simply required to respect and not
interfere with his or her choices. From the point of
view of autonomy competency, if such individuals
could critically self-reflect and realize the social
source of their negative self-conceptions, they would,
at least, have the opportunity to evaluate their per-
sonal worth and self-conception against their own
genuinely held beliefs, values, and achievements.
Their choices, like their mistakes, are in a significant
part, the business of social justice.
If nurses are to genuinely promote autonomy, they
need to draw upon highly developed linguistic, cog-
nitive, emotional, and communicative skills similar to
those employed by trained counsellors. This is
because autonomy concerns the exercise of a set of
competencies which underpin the ability to consult
oneself; the ability to scrutinize one’s beliefs, values,
and character traits; the ability to evaluate and prior-
itize those values and traits; the ability to act upon
those evaluations; and the ability to correct oneself,
with the ultimate aim of living in harmony with one’s
authentic self. Because our self-conceptions are
formed by processes of socialization, autonomy is
never merely the expression of an individual free will,
but rather, the result of a society of thoughtful, liter-
ate, and just institutions, inhabited by thoughtful, lit-
erate, and just individuals. Perhaps the most effective
role that a nurse can play in promoting autonomy is
to take steps to ensure that he or she acquires the
necessary competencies in order to become a
thoughtful, literate, and just individual.
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