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Sunday, October 24, 2021

Evaluating Tradeoffs between Autonomy and Wellbeing in Supported Decision Making

Veit, W., Earp, B.D., Browning, H., Savulescu, J.
American Journal of Bioethics 

A core challenge for contemporary bioethics is how to address the tension between respecting an individual’s autonomy and promoting their wellbeing when these ideals seem to come into conflict (Notini  et  al.  2020).  This  tension  is  often  reflected  in  discussions  of  the  ethical  status  of guardianship and other surrogate decision-making regimes for individuals with different kinds or degrees of cognitive ability and (hence) decision-making capacity (Earp and Grunt-Mejer 2021), specifically when these capacities are regarded as diminished or impaired along certain dimensions (or with respect to certain domains). The notion or practice of guardianship, wherein a guardian is legally appointed to make decisions on behalf of someone with different/diminished capacities, has been particularly controversial. For example, many people see guardianship as unjust, taking too  much  decisional  authority  away  from  the  person  under  the  guardian’s  care  (often  due  to prejudiced attitudes, as when people with certain disabilities are wrongly assumed to lack decision-making capacity); and as too rigid, for example, in making a blanket judgment about someone’s (lack of) capacity, thereby preventing them from making decisions even in areas where they have the requisite abilities (Glen 2015).

It is  against  this  backdrop that  Peterson,  Karlawish, and  Largent (2021) offer  a  useful philosophical framework for the notion of ‘supported decision-making’ as a compelling alternative for  individuals  with  ‘dynamic  impairments’  (i.e.,  non-static  or  domain-variant  perceived mpairments  in  decision-making  capacity).  In  a  similar spirit,  we  have  previously  argued  that bioethics would benefit from a more case-sensitive rather than a ‘one-size-fits-all’ approach when it comes to issues of cognitive diversity (Veit et al. 2020; Chapman and Veit 2020). We therefore agree with most of the authors’ defence of supported decision-making, as this approach allows for case- and context-sensitivity. We also agree with the authors that the categorical condemnation of guardianships  or  similar  arrangements  is  not  justified,  as  this  precludes  such  sensitivity.  For instance, as the authors note, if a patient is in a permanent unaware/unresponsive state – i.e., with no  current  or  foreseeable  decision-making  capacity  or  ability  to  exercise  autonomy  –  then  a guardianship-like regime may be the most appropriate means of promoting this person’s interests. A similar point can be made in relation to debates about intended human enhancement of embryos and children.  Although some critics  claim that  such interventions  violate the autonomy  of the enhanced person, proponents may argue that respect for autonomy and consent do not apply in certain cases, for example, when dealing with embryos (see Veit 2018); alternatively, they may argue that interventions to enhance the (future) autonomy of a currently pre-autonomous (or partially autonomous) being can be justified on an enhancement framework without falling prey to such objections (see Earp 2019, Maslen et al. 2014).