ABSTRACT

Beyond the Bioethics Principle of Autonomy:
Decisionally-Impaired Adults and a Vision of the Human Good

John R. Berkman, Ph.D.

In his recent book Playing God? Human Genetic Engineering and the Rationalization of Public Bioethical Discourse (2002), sociologist John H. Evans narrates the history of bioethics since its origin in the 1960's. He argues that the decision by the Department of Health, Education, and Welfare in the early 1970's to regulate experimentation involving human research subjects in the light of the Belmont Principles (i.e. the “principalism” embodied in Beauchamp and Childress' Principles of Biomedical Ethics) gradually led to the enshrinement of “autonomy,” “beneficence,” “non-maleficence,” and “justice” as THE principles of biomedical ethics in mainstream American society. Tristram Engelhardt in The Foundations of Bioethics (1986, p. 5) has referred to this form of bioethics as "a special secular tradition that attempts to frame answers in terms of no particular tradition, but rather in ways open to rational individuals as such."

Whatever other difficulties may inhere in a 'principalist' bioethics, principalist bioethics has a particularly difficult time addressing decisions regarding children and decisionally-impaired (i.e. legally incompetent) adults, because they do not neatly fit into its paradigm which begins with a presumption of autonomy. In these kinds of cases, appeal is typically made to the possibility of one or another form of "proxy consent." This presentation will argue that proxy consent decisions do not appeal to the principle of autonomy, but depend on an account of the "best interests" or the "good" of the incompetent individual, which in turn requires an articulation of the good of the human person.

The presentation will address this key inadequacy of the principalist approach to bioethics. It will then articulate an account of the human good, the need for which is particularly palpable in cases where there is a loss of autonomy and informed consent. It will look to the resources of a much older and still vibrant tradition of medical ethics, namely, medical ethics as it has been and continues to be done in the Catholic tradition.

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