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Respect for autonomy.

To a great extent modern biomedical ethics emerged out of concerns about failures to respect the autonomy of patients and research subjects. Their choices often were not sought or were overridden to benefit them or others. Despite a predictable backlash against the principle of respect for autonomy, it still holds, and should hold, a central place in biomedical ethics in a liberal society in the 1990s. Debate rightly continues about the proper meaning, scope, and strength of the principle. It has been criticized in part because its proponents have often extended it beyond reasonable boundaries and claimed too much weight for it over against other principles and values. Properly interpreted, specified, and weighted, however, it still has a major role to play in modern biomedical ethics, as indicated, for example, by ongoing problems in research ethics. But a major role is not necessarily a dominant or exclusive role. Critics of the principle rightly challenge interpretations that inadequately attend to the self's location in time and community. These themes of time and community are central in several of the following points that require further attention as the role of the autonomy principle in biomedical ethics is reaffirmed but also clarified and perhaps modified. (1) Respect for autonomy is an important moral principle for research, medicine, and health care, alongside other equally important principles. The hard task for biomedical ethics is to determine the principle's range and strength relative to other moral principles in various contexts. On the one hand, it is specified in several moral rules, such as informed consent, privacy, and confidentiality. And further specification is necessary to determine its proper range and scope, especially in relation to other principles. On the other hand, while it is weighty and stringent, it is not absolute. As one among several important principles, it is prima facie binding, but it can be justifiably overridden under some conditions. (2) Respect for an agent's autonomy presupposes an interpretation of the agent's relevant actions and preferences. Too often only an agent's literal statements are admitted into evidence about his or her preferences. However, as persons are complex and the process of communication is complex, it is appropriate to consider the agent's preferences as expressed in a variety of relevant actions, not merely, for example, in signing a consent form, however decisive that may be for legal purposes. (3) Apart from the most dramatic crises, agents' choices in health care most often occur over time. For instance, consent itself is given or withdrawn over time. Hence, it is essential to consider the temporal dimensions of past, present, and future in determining an agent's preferences. (4) Critics sometimes charge that the principle of respect for autonomy is a minimalist standard. They often concentrate on agents' assertions of their own autonomy rights, rather than noting that the principle also generates significant obligations to respect the autonomy of others. …