Reid Ewing and the Failure of Autonomy in Bioethics

Reid Ewing of Modern Family fame recently wrote publicly about his struggle with body dysmorphia in a personal essay on the Huffington Post. Ewing revealed that his dysmorphia led him to seek and receive several surgeries. He feels his surgeons should have recognized his mental illness and refused to perform surgery. He wrote, “Of the four doctors who worked on me, not one had mental health screenings in place for their patients, except for asking if I had a history of depression.”

The principle of autonomy is by far the most discussed principle of bioethics. Discussions typically focus on the rights of patients to refuse treatments, not to seek them. On either side, the issues can be thorny. If a depressed and suicidal patient refuses life-prolonging treatment, is it ethical to respect the patient’s autonomy or should mental health services be provided first? As in Ewing’s case, the ethical problem arises from the claim that the decision is driven by mental illness and not reason. If someone is mentally ill, they are not fully autonomous agents as they are not fully rational.

This is a problem with autonomy in general. Our ideas of autonomy come largely from Immanuel Kant, who claimed that all rational beings, operating under full autonomy, would choose the same universal moral laws. If someone thinks it is okay to kill or lie, the person is either not johnny-automatic-gloved-hand-with-scalpel-800pxrational or lacks a good will. How do we determine whether someone is rational? Usually, most of us assume people who agree with our decisions are rational and those who do not are not rational. If they are not rational, they are not autonomous, so it is ethical to intervene to care for and protect them.

Earlier this year, a woman named Jewel Shuping claimed a psychologist helped her blind herself. She says she has always suffered from Body Integrity Identity Disorder (although able-bodied, she identified as a person with a disability). Most doctors, understandably, refuse to help people damage their healthy bodies to become disabled, which can lead clients to desperate measures to destroy limbs or other body parts, sometimes possibly endangering others.

Jewel Shuping never named the psychologist who may have helped her, so it is impossible to check the story. It is possible to imagine, however, that some doctors would help someone with BIID in the hopes of preventing further damage to themselves or others. Shuping says she feels she should be living as a blind person, and she appreciates the help she received to become blind. In contrast, Ewing feels he should have undergone a mental health screening before he was able to obtain his surgery and that his wishes should not have been respected.

Plastic surgeons are often vilified as greedy and unscrupulous doctors who will destroy clients’ self-esteem only to profit from their self-loathing. On the other hand, these same plastic surgeons are hailed as heroes when they are able to restore beauty to someone who has been disfigured in an accident or by disease. Unfortunately, we do not have bright lines to separate needless surgery to enhance someone’s self image and restorative surgery to spare someone from a life of social isolation and shame. Some would argue the decision should not be up to the doctors in the first place but should be left in the autonomous hands of clients.

Many have similarly argued that doctors should refuse gender confirmation surgery to transgender men and women. As with BIID, many assume that transgender individuals are mentally ill and should see a mental health professional, not a surgeon. Transgender activists (and I) argue that transgender individuals need empowerment to live as the gender that best fits what they actually are. If surgery helps them along that path, they should have access.

All this leaves us with the question of when to respect autonomy and when to take the role of caregiver, which may involve a degree of paternalism (or maternalism for that matter). Is it more important for doctors who ensure the patient’s rights to seek whatever treatment they see fit, or is it more important to provide a caring and guiding hand to resolve underlying mental health issues before offering any treatment at all?

One of Ewing’s complaints is that he was offered plastic surgery on demand with no screening at all. The process for people seeking gender confirmation surgery, by contrast, is arduous. Before surgery, transgender people go through counseling and live as their true gender for an extended period of time. At the far end of the spectrum, people with BIID rarely find doctors willing to help them destroy parts of their bodies and resort to self-harm. These three cases are not the same, but make similar demands on the distinctions between respect for autonomy and a commitment to compassionate care.

It seems reasonable to accept Ewing’s claim that mental health screenings should be a part of body modification surgery, especially when someone has no obvious flaws that need to be repaired. In all these cases (dysmorphia, gender identity, and BIID), mental health support is necessary. In each case, patients describe depression, emotional turmoil, and, too often, thoughts or attempts of suicide. Mental health care does not require a violation of autonomy, but it may help a person’s autonomous decisions to form more clearly from deliberation and not desperation.

 

Religion and Morality: You could do more

Immanuel Kant said, “Morality is not properly the doctrine of how we may make ourselves happy, but how we may make ourselves worthy of happiness.” In the past I was of the opinion that if a moral system makes people miserable, it is not a useful moral system at all, but I think perhaps I’m finally starting to grasp Kant’s meaning. Sometimes it takes me longer than I’d like to get things.

It seems to me now that there are two ways of viewing morality. First, we may seek out systems that give us guidance on how we may improve ourselves. Second, we may seek out systems that validate how we already are.

Over the past few decades (or is this problem much older?), we appear to have embraced a massive self-esteem movement that compels us to seek self-validation rather than self-reflection and self-criticism. Christian mega-churches now teach people that God wants them to be happy, so they should pursue whatever makes them happy: luxury homes, cars, vacations, or other possessions. No more are congregants taught the value of restraint and humility. Thus, immediate and intense gratification is combined with the arrogance of ones who must not be questioned. It is not that I want to see medieval flagellants in the streets, but humble servitude and stewardship might be a nice change. I do realize, of course, that such meek worshipers still exist, but they are too quiet to gain so much notice.

And many people who claim to be interested in Buddhism say that it helps them stay centered. By this, they mean, as far as I can tell, that it helps them cope with the stresses life throws their way. But Buddhism as I understand it teaches discipline and awareness of the suffering of life. Suffering is universal, and relief from suffering must also be universal. To relieve your own suffering, you must stop believing in your “own” suffering and work to relieve universal suffering through loving kindness that pervades all your actions, words, and thoughts.   Your relief comes from the kindness you show others and your restraint from pursuing selfish desires, not from freeing your mind of unpleasant thoughts.

Finally, those who are not religious often turn to moral philosophy as a source of comfort. Rather than evaluating a moral system to see how sound it is and what advice it can offer for living a life that is good, proper, and noble, we read for a philosophy that exalts someone who is very much the way we already are.

When corporate leaders and other public figures are criticized for immoral behavior, they often react angrily and declare that it is their critics who are acting inappropriately. Of course, not all criticisms are valid, so sometimes they are correct, but imagine a world where the same people responded with an air of humility. We’ve entered an age where we constantly demand apologies of anyone in the public who says something we don’t like. I find apologies on demand to be extremely unsatisfying. I would much rather hear someone say, “I try to be a good person, but sometimes I make mistakes. I would ask you to show me the same forbearance and forgiveness that I promise to show you.” And maybe we can all set to the task of improving ourselves and our world.

On Lying

Anyone who has taught an introductory course in ethics has discussed the morality of lying, and most of us find that few people endorse an absolute prohibition against lying. Though we like to reject “situation ethics,” we tend to say that whether one should lie “depends on the situation.”

Lies
Lies (Photo credit: Gerard Stolk (vers l’Avent))

Against Kant’s absolute prohibition of lying, we offer the Murderer at the Door who wants to kill our innocent children. Surely, we should lie to throw the murderer off the trail of our children and, one would hope, into the hands of the police. This kind of lie is justified because it saves or has the potential to prevent great harm, or so it seems to some of us who don’t find Kant compelling.

On the other end of the spectrum, we find ourselves wanting to demand the truth even when dishonesty (or withholding the truth) appears harmless. We have the case of police who have taken embarrassing photos of an assault victim to be used as evidence against the perpetrator but who then use the photos for the amusement of themselves and their colleagues. The victim may never be affected by this secondary use of the photos so long as the victim remains completely unaware of them. Doing such a thing seems quite wrong, though, or at least it does for me.

In relationships, we have all kinds of information that could help or hurt our partners. Should we tell them what their friends have said about them behind their backs? Should we go so far as to tell a complete lie (“No, Susan has never said an unkind word about you!)? Learning every detail of what your friends and colleagues have said about you is likely to be painful at best. I personally recommend sheltering yourself from this as much as possible. I also think it is possible to share too much information.

On the other hand, if your friends are so hateful towards you that they cannot be considered friends, you might want to know that. So, we are tempted to say we want complete honesty except when it is more painful or harmful than a lie. This leads to the problem that we do not always know what is better or worse in the end. Lies have unintended consequences, and we feel responsible for their consequences while we do not feel personally responsible for the consequences of the truth, although many people have said something along the lines of “I never should have told the truth!”

So, we are left with decisions based on the context and situation. We must choose between protecting someone’s feelings and offering full disclosure. There are a number of things we can consider in our decisions. First, I think we may consider how the other person will react if the dishonesty is discovered. Many people have said that if their death is imminent, they would want their friends and family to lie to them.

We can also consider our own motivation for the lie. Are we lying to protect others or to protect ourselves from taking responsibility for our own actions? When we are only trying to cover our own footprints to avoid having to confront truths about ourselves or our actions, I think the lie is most likely not justified.

Finally, as much as consequences cannot be predicted, we really must think of what outcome we are trying to achieve. In many ways, this last consideration echoes the first two, but it deserves a little focus on its own. We must think of what good the lie may produce if it is believed and what pain it may produce if it is exposed. I suppose we must also attempt to evaluate what pain may result if a lie is believed. (E.g., what is the harm in telling people they will live 10 years when you know they have only a few hours left?)