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PROBLEMS OF PSYCHIATRIC ADVANCE DIRECTIVES 455
4. Voluntary Informed Consent and Thick Respect for Autonomy
Philosophers often distinguish two kinds of respect for persons as autonomous. The first is
simple respect for autonomy, which is often represented by libertarians. It says that each
person has the right to make her own decisions regardless of how rational they are and
regardless of potential harmful consequences. Paternalistic intervention is never allowed
according to thin respect for autonomy. By contrast, according to thick respect for autonomy,
each person has a right to be treated as autonomous in the sense that it is to be ensured that
the standards of making rational choices are met. “By insisting on the importance of informed
consent we make it possible for individuals to choose autonomously” 27 , O’Neill argues.
Paternalistic intervention seems to be allowed to a certain degree – e.g. by seeking voluntary
informed consent – if a person obviously is not aware of the consequences of her actions or
finds herself in a situation where she cannot make competent decisions.
The criterion of voluntary informed consent is therefore closely connected with thick respect
for autonomy. Beauchamp and Childress present a “five-element definition” of informed
consent that is widely acknowledged: “One gives an informed consent to an intervention if
(and perhaps only if) one is competent to act, receives a thorough disclosure, comprehends
the disclosure, acts voluntarily, and consents to the intervention”. 28 There has been lots of
debate whether voluntary informed consent is necessary and/ or sufficient for autonomy.
Many philosophers agree that the notion of autonomy is not sufficiently defined by equating it
with voluntary informed consent. As we have seen from the discussion above, there are
multiple ways to define autonomy and most of them are not restricted to voluntary informed
consent. In medical ethics most philosophers argue that voluntary informed consent is
necessary for autonomy. If a person who is able to give voluntary informed consent does not
give voluntary informed consent, his right to autonomy is not respected. Still, the right to selfdetermination
does not include the capacity to make use of this right.
Therefore, even though the patient’s decision and autonomy should be respected in as many
cases as possible, there are cases in which persons lack the capability of making competent
decisions. This seems to justify paternalistic intervention:
Our 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 examples. 29
There seem to be cases in which it is justified to disregard a patient’s autonomy and to act
paternalistically on him. There are two forms of paternalism. Soft paternalism says that it is
permissible to prevent someone from acting to make sure whether he satisfies conditions of
voluntary informed consent. Hard paternalism means that it is permissible to prevent a
person from acting in order to prevent harm from coming to that person. I share Gerald
Dworkin’s opinion that “the difficulty is in specifying in advance, even vaguely, the class of
cases in which [paternalistic] intervention will be legitimate”. 30 In order to lay down the
boundaries for autonomy, it is important to determine under which circumstances it should
be allowed to override a person’s will, because these cases are an exception to the general rule
that a person’s autonomy always trumps.
27
O’Neill 2002, p. 37.
28
Beauchamp & Childress 2001, p. 120.
29
Beauchamp & Childress 2001, p. 105.
30
Dworkin 1983, p. 33.