1.1 Introduction
My aim is to provide an egalitarian account of moral respect as it applies in health care contexts. The concept of respect is central to medical ethics. Some discussion of ârespectâ has been part of medical ethics since the early days of the discipline (e.g. The Belmont Report 1979). The dominant discussion of ârespectâ in the context of health care ethics focuses on ârespect for autonomyâ and this conception is well-entrenched in legal frameworks in a number of countries. The conception of ârespect for autonomyâ leaves a gap in medical ethics because it does not apply to those patients who are not autonomous. In the seventh edition of The Principles of Biomedical Ethics, Beauchamp and Childress explicitly write that the principle of respect for autonomy does not include those who are not autonomous and cannot be rendered autonomous, such as children or patients diagnosed with late-stage Alzheimerâs disease. They state that those who are not autonomous are still covered by the concept of moral respect (Beauchamp and Childress 2013, p. 108). The concept of moral respect remains unanalysed in their edition, however. I fill this gap by reframing questions about moral respect around the role that the concept plays in our moral lives. I suggest that the fundamental role of moral respect is to recognize a person as more than a mere object, as an entity with intrinsic value of dignity rather than merely use-value of price.
To further explore the role of respect as recognizing someone as more than a mere object, I consider what it means to treat someone as an object. I suggest that disregarding someoneâs autonomy or violating their autonomy is one important way of treating someone as a mere object. So respect for autonomy will remain central on my account. There are, however, a number of additional ways that we can reduce someone to a mere object and I pay particular attention to these additional forms of objectification.
I describe three aspects of the concept of respect: the grounds of respect, the target of respect and the behaviour that enacts respect. The ground or basis of respect tells us why respect is owed or warranted. The target of respect identifies what sorts of things must be respected. The behaviour that enacts respect describes how respect is put into practice in respectful relationships (Dillon 2010). A concept of moral respect should be egalitarian in the sense that it should apply equally to all persons, or members of the moral community. I suggest that we should understand respect as a concept that is grounded in dignity, which recognizes both the absolute moral value of individuals as well as the concrete particularity of their perspectives. As a result, the target of respect on this view is the person themselves, rather than an abstract feature or fact about the person. Respect is enacted through interactive second-person asymmetrical relations that treat others as more than mere objects. We disrespect others when we reduce them to mere objects, and so I consider what it is to objectify someone. There are a number of way to treat someone as an object, so the account of respect that I offer is relational and pluralist.
1.2 Respect for Autonomy and Informed Consent
The most common and legally-entrenched conception of ârespectâ in health care ethics and law focuses on respect for autonomy, where autonomy is understood as making informed, voluntary choices about particular medical treatments or other aspects of care. This kind of autonomy is protected by ensuring that patients are well-informed about their condition and treatment options and that patients can give voluntary consent or refusal to these treatments. This conception of respect and its protection through informed consent is important and deserves its central place in medical practice and health law. Nothing in my discussion would undermine the importance of respect for autonomy. Respecting the autonomous decisions of competent patients is a necessary component of respecting them. Violations or denials of autonomy remain one important way that the moral equality of autonomous patients can be denied. Instead, my claim is that respecting autonomous decision is not sufficient for moral respect in health care settings. There are two reasons that it is not sufficient. First, it is inegalitarian because it does not apply to non-autonomous patients. Second, there are cases where even autonomous patients can arguably be disrespected even while their choices about medical treatments are accepted and they have given competent informed consent. To make these two criticism clear I begin by describing Beauchamp and Childressâ influential discussion of respect for autonomy. They themselves note that this conception of respect does not apply equally to all patients. The second claim will be developed throughout this chapter and the rest of the book.
On Beauchamp and Childressâs account, the grounds, object, and obligations of respect all centre on capacities for autonomous decision-making and supporting patients in making autonomous decisions. The understanding of âautonomyâ that Beauchamp and Childress invoke focuses on localized, specific instances of autonomous choice, rather than a broader conception that understands âautonomyâ as abilities, skills, or traits of the person (2009, p. 100; 2013, p. 102). Beauchamp and Childress select âautonomyâ as the grounds of our obligations of respect in health care contexts because they want âto be as precise as possible about what is and must be respectedâ (Beauchamp and Childress 2009, p. 70; 2013, p. 68). They eschew the language of respect for dignity and respect for persons because they believe that the terms âdignityâ and âpersonâ are vague and inherently contestable (2009, pp. 66, 69â70; 2013, pp. 65, 68).
The object of respect is also autonomous decision-making on Beauchamp and Childressâs view. That is, the presence of competence and other capacities for autonomous choice both explains why we must respect autonomous decisions, and autonomous decisions are the target of our respect. Since the early editions of Principles of Biomedical Ethics Beauchamp and Childress have contended that when we show respect to patients, the target of our respect is their choice; however, the obligations of respect have strengthened over subsequent editions. In the first edition, Beauchamp and Childress tell us, âTo respect autonomous agents is to recognize with due appreciation their own considered value judgements and outlooks even when it is believed that their judgements are mistaken. To respect them in this way is to acknowledge their right to their own views and the permissibility of their actions based on such beliefsâ (1979, p. 58). These obligations focused on granting persons the right to their own views, and the negative prohibition on interfering with their liberty. In more recent editions, Beauchamp and Childress have strengthened these requirements considerably and now require positive elements that acknowledge âthe value and decision-making rights of persons and [enable] them to act autonomouslyâ (2009, p. 103; 2013, p. 107). This involves ârespectful action, and not merely a respectful attitudeâ (Beauchamp and Childress 2013, p. 107; emphasis in original). The respectful actions include such things as providing information, building up the capacity for autonomous choice, and dealing with emotions, such as fear, or other conditions that might distort autonomous actions. In contrast, disrespect for autonomy involves actions and attitudes that âignore, demean, or are inattentive to othersâ rights of autonomous actionâ (Beauchamp and Childress 2009, p. 103; 2013, p. 107). On this view, the behaviours and attitudes associated with both respect and disrespect focus on autonomous decision-making.
Although Beauchamp and Childressâs account of ârespectâ is clearer than some of the discussions of respect found within general mainstream bioethics, this clarity is bought at a price when we consider the scope of respectâthat is, to whom (or what) respect is owed. Because Beauchamp and Childress take autonomy as the object of respect, on their view our obligations related to this kind of respect extend only to those who are autonomous or those who have expressed their wishes through advance directives. They write, âOur obligations to respect autonomy do not extend to persons who cannot act in a sufficiently autonomous manner (and who cannot be rendered autonomous) because they are immature, incapacitated, ignorant, coerced or exploited. Infants, irrationally suicidal individuals, and drug-dependent patients are examplesâ (2009, p. 105). In the seventh revision to their view, Beauchamp and Childress have added the sentence âThis standpoint does not presume that these individuals are not owed moral respect. In our framework, they have a significant moral status⊠that obligates us to protect them from harm-causing conditions and to supply medical benefitsâ (2013, p. 108). Interactions with those who cannot act sufficiently autonomously will still be subject to the remaining three principles of beneficence, non-maleficence, and justice. Beauchamp and Childress offer a vague suggestion that non-autonomous patients will still deserve some form of respect. This other form of respect, that Beauchamp and Childress call moral respect remains unanalysed in their book, however. I infer that Beauchamp and Childress recognize that their account of respect is inegalitarian in that it treats autonomous and non-autonomous patients differently while moral respect is egalitarian and would require respect for patients regardless of their decision-making capacities. This latter form of egalitarian moral respect is my focus in this book.1
1.3 Cases of Disrespect?
My second criticism, that respect for autonomy is not sufficient for moral respect even among autonomous patients, is more difficult to establish. To...