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introduction

Despite its global reception, Tom L. Beauchamp and James F. Childress’ principle of respect for autonomy has been the subject of questions, debates and criticisms, especially from scholars outside the Anglophone world. A representative critique is this comment: “Critics argue that the principle of autonomy, in particular, the idea of individual informed consent proposed by Beauchamp and Childress, has a strong Western bias and hence cannot be applied to non-Western countries such as China, Japan, and most African nation-states in which family- or community-informed consent is prevalent” (1).

In this article, we address two long-standing objections raised by scholars specialising in Confucian ethics, namely that Beauchamp and Childress’ principle of respect for autonomy 1) exalts individual autonomy and 2) ignores family-based medical decision-making. The authors of this commentary are two Chinese Singaporeans who are familiar with Confucian beliefs, values and lifestyles. Our objective is to defend Beauchamp and Childress’ principle of respect for autonomy against the above-mentioned objections. Such a defence is significant as it invites researchers in bioethics to rethink the alleged Western-orientation of Beauchamp and Childress’ principles and their suitability in diverse healthcare settings. It is also important to acknowledge Confucian viewpoints concerning biomedical ethics since they constitute a foundation of moral worldviews and practices in East Asia.

The PRINCIPLE OF RESPECT FOR AUTONOMY

Beauchamp and Childress identify the negative and positive sides of respect for autonomy, which take the form of a negative and a positive obligation (2). As a negative obligation, the principle holds that autonomous actions are free of controls from external sources such as coercion from another person or by internal states such as the patient’s mental illness. As a positive obligation, the principle calls for respectful attitudes and actions towards the patient so as to promote the latter’s autonomous decision making. Examples of positive obligations include disclosing information and available options to the patient, checking for understanding and ensuring that the patient’s decision-making is voluntary. Beauchamp and Childress also clarify that the principle of respect for autonomy is not absolute and instead has only prima facie standing; this principle can be overridden by competing moral considerations in specific circumstances. The determination of whether and how the principle of respect for autonomy can be overridden depends on what Beauchamp and Childress call ‘specification.’ Accordingly, specification spells out the particular contexts, including exceptions, for the functioning of the principle of respect for autonomy — we will return to this in a later section when we discuss our responses to the Confucian objections.

On Individualism

The first Confucian objection is that the moral paradigm that underlies Beauchamp and Childress’ framework for biomedical ethics “is that of individuals acting alone autonomously, namely the paradigm of liberal democratic moral and political understandings” (3). In other words, the principle of respect for autonomy is criticised for championing individual autonomy, where a person makes decisions and acts independently. Relatedly, researchers have raised the concern that the principle of respect for autonomy is influenced by Anglo-American values and worldviews, and may not be culturally appropriate for non-Western countries such as China (4-6).

In response, the first point to note is that Beauchamp and Childress have, on more than one occasion, clarified that their principle of respect for autonomy does not privilege individualism (8). They claim that the principle of respect for autonomy is only prima facie binding, in the sense that the principle can be overridden by other prevailing moral considerations, such as protecting patients from unnecessary anxiety and agony. They give the example of a physician who received a patient’s myelogram results that suggested a serious pathology. The physician was informed that the test results were inconclusive and that the test needed to be repeated. Despite knowing that the patient had the right to know the test results, the physician chose not to disclose the potentially negative information to the patient. Beauchamp and Childress explain why the principle of respect for autonomy should be overridden in this case:

Her [the physician’s] sole motivation in withholding the information is to spare the patient the emotional distress of processing negative information, which seems premature and unnecessary. However, the physician intends to be completely truthful with the patient about the results of the second test and intends to disclose the information well before the patient would need to decide about surgery (2, p.221-2).

Notwithstanding this clarification, critics could counter that Beauchamp and Childress are still operating within an individualistic worldview. In the above example, the patient is the sole decision-maker and is free to act as they wish regarding their illness and treatment. The Confucian objection is directed to Beauchamp and Childress’ description of individuals acting alone without the involvement of other people, especially one’s family. Put otherwise, proponents of Confucian bioethics question the perceived assumptions of independence and self-reliance in Beauchamp and Childress’ principle of respect for autonomy.

However, this critique is a misunderstanding of Beauchamp and Childress’ principle of respect for autonomy. Instead of restricting medical decision-making to individual patients and viewing them as atomistic and isolated, Beauchamp and Childress acknowledge the right of individuals to delegate decision-making to other people. They write that individuals may freely choose to rely on “an institution, tradition, or community that they view as a legitimate source of direction” (2, p.105), and add that “Even if the patient delegates that right to someone else, the choice to delegate can itself be autonomous” (2, p.109).

Contrary to the claim by advocates of Confucian bioethics, Beauchamp and Childress’ principle of respect for autonomy does not celebrate or presume individualism. As explained earlier, Beauchamp and Childress have stated explicitly that they do not endorse individualism; they have also clarified that the principle can be overridden by prevailing ethical concerns, and they recognise the right of individuals to delegate decision-making to other people. To be clear, Beauchamp and Childress did not directly link their principle of respect for autonomy to the Confucian values of human interdependence and the central role of the family. In this regard, they could have elaborated further on how the exercise of autonomy is embedded in and reflects human relationships and inter-connectedness.

Compatibility with Family-Based Medical Decision-Making through Specification

Turning to the second objection, that medical decision-making in societies shaped by Confucian values is seldom undertaken by the patient alone (3). Rather, in East Asia, family members are often actively consulted in physician-patient relationships, medical decision-making and consent to medical treatment (7). Beauchamp and Childress’ principle of respect for autonomy, it is argued, does not sufficiently acknowledge the importance and function of the family in medical ethics. Our contention, however, is that Beauchamp and Childress’ principle of respect for autonomy is in fact compatible with family-based medical decision-making through specification.

According to Beauchamp and Childress, specification seeks to concretise abstract norms and engender rules by elaborating on the actions that need to be carried out or avoided. Different cultural values and standards may lead to differing specifications of the same moral norm. Beauchamp and Childress relate specification to the Confucian emphasis on filial piety by noting that

some scholars in Hong Kong stressed that Confucian ethics, in contrast to more liberal, individualistic frameworks in Western societies, takes for granted obligations and virtues of filial piety, recognizes obligations of children to care for their parents, and argues that governments should promote the fulfilment of those filial obligations. This kind of moral diversity in identifying moral agents and their responsibilities is certainly within the bounds of principles derived from the common morality and in no way contradicts them. Making the principles more determinate in identifying who should be the primary moral agents and what they should do in caring for elders in a society requires specification or balancing or both (9, p.172).

Returning to the Confucian objection, it can be countered that Beauchamp and Childress’ principle is compatible with family-based medical decision-making through specification. The process of specification for elderly patients living in Hong Kong and other East Asian societies involves making the principle of respect for autonomy more determinate by “identifying who should be the primary moral agents and what they should do in caring for elders in a society”.

On the first question of who should be the primary moral agents, specification entails that the primary moral agents may refer to not only the elderly patient but also one’s adult children. The Confucian values of filial piety and family harmony mean that the medical decision-making is a shared one between the patient and family members (10). This family-based medical decision-making approach applies even when the patient is not an elderly person but someone younger. For instance, an adult patient in Confucian-influenced societies is likely to involve one’s parents and siblings when making major medical decisions. The Confucian idea of family-based medical decision-making means that no family member, including the parent, should disregard or overrule the wishes of the patient. Doing so contradicts the Confucian value of harmony (he) and normative behaviour (li). Rather, a consultative approach is advocated where the family arrives at a medical decision that reflects empathy (shu) and humaneness (ren).

As to the second question of what the moral agents should do in caring for elders, specification enables a plurality of practices that are shaped by varying sociocultural ethos. Consistent with the community-orientation of Confucian ethics, family members of an ailing elderly patient are likely to prefer family consent or surrogate decision-making for the patient’s medical treatment. Beauchamp and Childress’ principle of respect for autonomy is therefore congruent with an elderly patient’s desire to delegate the medical decision-making to one’s children.

What about the controversial practice of not disclosing the sickness to the patient and excluding the patient from the informed consent process? On this issue, Beauchamp and Childress’ principle of respect for autonomy does not demand that the physician always reveals the diagnosis to the patient, even when the patient asks for it. As noted earlier, this principle is only prima facie binding and can be overridden by other ethical considerations. Beauchamp and Childress state that “virtues and principles work together in practical situations — for instance, in the disclosure of bad news to patients with special attention to delaying or staging this disclosure in the context of both caring for and respecting the autonomy of those patients” (2, p.11).

Turning to the issue of replacing individual’s informed consent with family informed consent, the essential question is whether the individual has delegated to their family the decision-making process, including giving or withholding consent to medical treatment. If delegation is involved, then this practice is compatible with Beauchamp and Childress’ principle of respect for autonomy and specification. The principle does not insist that patients make all the medical decisions on their own, and instead makes provision for the family to participate in medical decision-making. Delegation means that the patient has expressly indicated a wish to be excluded from the medical decision-making and to leave the decision-making to one or more family members who function as the moral agents. Illustrating delegation, a researcher reports from an empirical study in Singapore that “a family-centred model to medical decision-making… did not appear to be at the expense of the patient’s autonomy if the patient was formally asked to indicate the preferred mode of decision-making, made the choice of a family-centred process, and retained opportunities to freely raise questions” (12, p.10).

In general, the exclusion of the patient’s informed consent without the knowledge or permission of the patient should be avoided because of the potential harm to the patient (13-14). If a patient is unable to give informed consent and the decision is determined by the family, the decisions made by the family may not always be in the best interests of the patient. As acknowledged by a researcher of Confucian ethics, “Chinese health care practitioners should be aware of how to protect their patients from being manipulated or coerced by the collectivist pressure (mostly from their families) and promote their autonomy without despising their traditional family values” (11, p.49).

Overall, Beauchamp and Childress’ principle of respect for autonomy is in concert with the Confucian idea of family-based medical decision-making through specification. That external constraints may undermine the patient’s autonomy and well-being justifies the necessity of the principle of respect for autonomy. Of course, the patient’s informed consent is not possible if the patient is unable to do so due to illnesses such as dementia. Guided by the medical, legal and ethical considerations, physicians must facilitate transparent conversations between patients and their families and make decisions that prioritise the patient’s health, wellbeing and dignity.

CONCLUSION

Focussing on a prominent Confucian critique of Beauchamp and Childress’ principle of respect for autonomy, this article has responded to the criticism that their principle privileges individual autonomy and overlooks family-based medical decision-making. We have argued that this principle does not lean towards individualism and is aligned with family-based medical decision-making through specification.