Uses and Abuses of Autonomy

If you’ve studied bioethics, you know that the principles of bioethics are autonomy, beneficence, non-maleficence, and justice. You also know that autonomy, especially in the early days, got most of the press. I was one of the people who saw bioethics and autonomyethics generally, really, as a matter of respecting autonomy. And I still think it is typically wrong to do things to people that they wouldn’t reasonably want done.

As it often happens when changing points of view, I first began to question the value of autonomy in the most extreme cases—those where someone had no autonomy at all. How do you show the proper respect to a cadaver for example? How should we go about respecting the autonomy of someone who is no longer conscious and may never regain consciousness? It seems that showing respect for a person’s life may not always mean respecting the person’s autonomy.

Even in those cases, though, we still try to preserve the notion of autonomy by calculating what would have been correct for that person if that person were a conscious being with autonomy. To what would a rational person want or be entitled? And here is a bit of muddy water already. Kant described respect for autonomy as respect for universal laws, not respect for individual wishes, for respecting someone’s wishes might only be to help them use themselves as a means (see: physician-assisted suicide). For Kant, respect for autonomy would mean that no one could morally choose to die, so certainly no one could morally help someone to die.

But we don’t adhere to Kant so closely, do we? So, respecting someone’s autonomy has come to mean respecting that person’s wishes by getting their consent before doing anything to them or not doing anything to them, as the case may be. But even having someone’s full-throated consent does not make it okay to do whatever we please, and we mostly recognize that. We have laws against doing things to children, for example, or to people with limited cognitive abilities because we recognize that some people are extremely vulnerable to exploitation.

We spend a lot of time trying to identify vulnerable populations, but my problem comes with trying to figure out who might not be subject to exploitation. It seems to me that even the most mature and intelligent people in the world are subject to exploitation at least some of the time. I can think of many examples, but one example is certainly whenever anyone gets sick.

I would say that anyone with even a minor illness has lost a degree of freedom. If I have something as simple as a stuffy nose, I will make decisions I would otherwise not make. You know, I may decide to give money to some stranger who promises that some chemical or other might make my breathing easier. If I will give away my money to avoid slightly congested breathing that will likely correct itself in a short time, what might I do to avoid rapidly approaching death?

If I’m frightened enough of dying, and most of us do want to avoid an early death, I might agree to almost any treatment dangled in front of me, and I might go to extreme measures to procure the treatment. Getting my consent to give me my only chance of relief seems a little strange, which is why neither healthcare providers nor their clients pay much attention to the whole informed consent process in routine cases. We generally go to healthcare providers with the intention of making use of the services they provide.

Yes, I know patients do need the information that makes up the “informed” part of informed consent, and sometimes genuine decisions must be made in collaboration with the doctor or other caregiver. Even in those cases where decisions must be made, most patients assume the doctor is in a better position to know what choice is best. Which is why so many of us respond with, “What would you do, Doctor?”

What we don’t say, though, is, “No, I don’t want any treatment. I only came in because I had a bit of free time and thought I’d spend it in an examining room.” It is only suffering, whether minor or extreme, that drives us to see a doctor. And it is that suffering that makes us vulnerable to exploitation, and that vulnerability renders the concept of free consent or undiminished autonomy questionable.

So I don’t think autonomy can shoulder the moral burden it is expected to carry. In fact, autonomy may not mean anything useful at all. Respecting a person’s wishes, especially in situations where wishes are so easily manipulated, may not be of any moral value at all.

Gender Disparity: Paycheck Fairness Act is not enough

Before I start, let me say that I support any effort to address wage inequality and I believe strongly in the right to equal pay for equal work. If the Paycheck Fairness Act helps to bring more equity to the workplace, I’m all for it, but it will not eliminate wage disparities between men and women on its own.

Republicans are wont to point out that women make less than men not because of discrimination but because of lifestyle choices. (Read a fuller discussion of this in The Guardian.) Their argument centers on the fact that it is possible to pay every woman in any given job the same wage as every man in a similar job and still end up with wage disparity because more women are in lower-paying jobs. To Republicans, this means sexual discrimination is not a problem (everyone should just choose to be a petroleum engineer or investment banker, right?), but for the rest of us it means that sexism is a pernicious problem that will not easily be solved with a piece of legislation.

First, we might ask why the jobs more women choose pay less than the jobs more men choose. One proposed answer is that men choose jobs that are riskier and require a more “masculine” personality. Women, it is assumed, will choose safer and less demanding jobs. Another answer is that women gravitate toward jobs that require fewer hours (they need to get home to the kids, you know?). And another is that women choose jobs that require less training.

According to the 2013 Physician Compensation Report, male doctors earn 30 percent more than female doctors. The report explains the disparity thus: “There are fewer women in some of the higher-paying specialties. For example, in orthopedics, only 9 percent of the survey respondents were women, whereas in pediatrics, 53 percent of survey respondents were women.”

Interestingly, the lowest paid specialty in medicine is now HIV/Infectious Diseases, which also happens to be the specialty with the second highest rate of overall satisfaction (just behind dermatology). The other low-paying specialties are family medicine, diabetes/endocrinology, and internal medicine. Other high-paying specialties, after orthopedics, are cardiology, radiology, gastroenterology, and urology.

While I can’t see that the risk of treating infectious diseases is lower than the risk of practicing urology, I do see that the lower-paid specialties focus more on care and concern and require human interaction. (It still may be true that women are more risk-averse, which may be why they are safer doctors.) It seems to me that we value technical expertise over human and care and concern in most fields. At least we are more willing to pay for technical expertise and less willing to pay for the care and concern that we will all need.

Teachers work hard and take many risks but will never earn as much as petroleum engineers. Ah, but petroleum engineers fatten the bottom line for their employers, you say. Let them try to survive without teachers to get them there. Let all the hard-working risk takers make it through life without the people who cared for them and helped them become successful. And men have always said this, haven’t they? We have clichés such as “Behind every successful man is a woman.” And women have done their work, largely, for free—because they had no other choice. So the work women have done is devalued (though prized in way) and undercompensated. If fewer people were willing to do “women’s work,” the price of such work may indeed rise, but I don’t see this happening any time soon.

And men sometimes choose work that may be seen as “feminized.” When they do, men also earn less because their work is undervalued, too. If the work were not undervalued, I aver that more men would choose different careers. After successful careers in industry, some men choose to leave their jobs for more “meaningful” work after middle age. The work people describe as “meaningful” or “rewarding” is almost always related to either caring relationships or creative enterprises; these are the activities that make life seem worthwhile.

Because these activities bring so much personal satisfaction, people are willing to do them for less pay. If petroleum engineering did not pay so well, I’m sure some people would still choose it as a profession, but many people choose it now only because it pays well and not because it enriches their lives in any other way. Many men are starting to reject the idea that they must choose careers based on how well they pay. Some men in the men’s movement reject being treated as “success objects.” Nonetheless, I think women are more likely than men to feel free to choose careers based on satisfaction rather than remuneration, and men are more likely than women to feel they must choose a career that pays well. There are many, many exceptions, of course, but not enough to close the pay gap between men and women.

So, what should we do to address the problem of wage disparity? First, stop devaluing “feminine” work. Recognize the true value of education and care. Second,  stop treating men as “success objects.” Remove the stigma from rejecting a high-powered career for a more rewarding and meaningful life. Finally, make it possible to find a balance between a career that pays well and a meaningful life. Some women may pass up high-paying professions because they do not want to neglect their family relationships or similar concerns. At the same time, some men neglect relationships and personally rewarding work because they feel obligated to earn as much as possible. Men and women would both behave differently if it were possible to enter any career without having to sacrifice family relationships, volunteer opportunities, and creative outlets. Another world truly is possible.

The Ethics of Caring and Seasonal Depression

I don’t know if it is the changes in the weather, the length of the days, or what, but we

The suicide
The suicide (Photo credit: Wikipedia)

sometimes find the world slipping away from us. As we reach, objects, people, and activities seem to continuously recede into the distance just beyond our grasp. We forget how to be engaged with even the most basic tasks. Seasonal changes can leave us feeling depressed and melancholy. As the poet Phillip Larken put it:

The trees are coming into leaf
Like something almost being said;
The recent buds relax and spread,
Their greenness is a kind of grief.

For reasons that aren’t completely understood, spring seems to bring a surge of depression and suicides, but winter gets all the attention for warnings about seasonal depression. Some researchers have noticed that suicide spikes coincide with increased pollen production.  Apparently, allergies release cytokines, which affect appetite, activity, sex drive, and social engagement. There may be a philosophical question in there as to the difference between having “depression” and having a response to allergies that looks a heck of a lot like depression. Sufferers of either will probably not worry the distinction too much.

Some theorists suggest that suicide peaks in spring because of a “broken promise effect.” When spring doesn’t bring the joy and energy it generally promises, the depressed are moved to suicide. Others have suggested that springtime brings more energy and agitation (and a corresponding drop in melatonin), especially to people with bipolar disorder, that moves them to act against their own lives.  Still others speculate that springtime increases in serotonin give people the energy to kill themselves.

I don’t want us to turn away from people who are depressed during the holidays. Rather, I just hope we can remember that some of us occasionally feel depressed and hopeless throughout the year. The extra effort we make through the holidays may be worth making year round.

Still, I know it is true that many of us mourn with greater intensity during the holidays as we count all those who are no longer with us and grieve for our losses, so maybe we should be a little extra careful during December. A little care can go a long way to avoiding a holiday crisis. But we should remember to keep caring and reaching out during the new year, into spring, and for the rest of the year. When we help each other, we are all stronger.