Traditional approaches to autonomy in bioethics generally accept that if a patient has the capacity to understand the information with which she is provided, appropriately reflects on and revises her beliefs and makes a decision in the light of that information, then her decisions should be respected. What is invoked is a picture of the introspective, integrated subject, who can distance herself from the beliefs of others as well as her own motivating mental states in order to endorse, identify with or respond to her motives through either an appropriate formal mechanism or process of critical reflection. Phenomenology, however, gives rise to certain ontological considerations that have far-reaching implications for standard bioethical conceptions of patient autonomy and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful.
This paper will build on and extend the analyses of the phenomenological reduction in the works of Husserl, Heidegger and Merleau-Ponty in order to identify and explain the implications of the phenomenological reduction for our current understanding of the principle of respect for patient autonomy. Firstly, on the basis that the phenomenological reduction implies that moods and practical, sensorimotor copings are as vital to the disclosure of the meanings of things, people and events as conceptual understanding and critical reflection, it will be shown that the affective and embodied dimensions of experience are integral parts of an agent’s normative authority to exercise their autonomy and should, therefore, be accorded appropriate recognition by health care providers in decision-making contexts. Secondly, rather than accept that autonomy is purely conditioned by cognitive processes of introspective self-reflection so highly valued in traditional accounts of autonomy in bioethics, it will be demonstrated that the phenomenological reduction supports a relational model of autonomy whereby a patient’s ability to exercise their autonomy is causally dependent upon her broader interpersonal relationships and social structures as well as the recognitive relationships that exist between the patient and her physician. Thirdly, this relational approach to autonomy entails that the exercise and achievement of autonomy is necessarily intersubjective, dialogical and reciprocal. Specifically, the phenomenological reduction generates an existential, normative obligation for agents to be answerable to one another. Consequently, the paper will illustrate that clinical decision making necessarily involves patients and physicians expressing to each other their affectively, corporeally and reflectively grounded claims in the space of reasons. Fourthly, it will be shown that the phenomenological reduction commits us to a normative pragmatic conception of clinical decision making whereby respect for patient autonomy requires the physician to recognise, assess the appropriateness of, and respond appropriately to, a patient’s commitments and reasons according to the norms built into health care practices.