The Principle of Autonomy in Biomedical- and Neuroethics.

Abstract

With appreciation toward those who commented and provided insight on “From reciprocity to autonomy in physician assisted death: an ethical analysis of the Dutch Supreme Court ruling in the Albert Heringa case” (Florijn 2022), I obtained an additional opportunity to clarify and advance my thinking about the concept of autonomy in biomedicaland neuroethics. In general, the ideal value of the principle of autonomy in biomedical ethics, as well as ‘in moral, political and social areas’, contains a ‘notion of the self which is to be respected, left unmanipulated, and which is, in certain ways, independent and selfdetermining’ (Dworkin 2015). In clinical settings, this ideal of self-legislation should be accessible and available to all (i.e. both physician and patient). Complementary to this approach is Immanuel Kant’s theory of autonomy that understands autonomy as a moral principle. Herein, autonomy is seeing the rational individual as a person agreeing to universal principles and as an end in itself (Genuis 2021). Autonomous acts are rational when in accordance with these principles, while laws should function as an expression of autonomy by reflecting a commitment to equality and respect (Reis-Dennis 2020). Furthermore, neurobiology pinpoints the emergence of the autonomous self and decision-making in cooperating complex systems (Bergareche and da Rocha 2011). A striking example is the ‘executive control theory’ which locates decision-making among a hierarchy of desires, analogous to neural structure, function and circuit activity, controlled by the prefrontal cortex. These neural circuits improve decisionmaking using (nonrational) information produced by emotional responses (somatic marker hypothesis), although they are still influenced ‘covertly by external sources’ outside of conscious awareness (extended mind theory) (Felsen and Reiner 2011). Given this context and the ruling of the Supreme Court, the aim of my response to the open peer commentaries is twofold. I argue the physician-patient relationship is constitutive for the principle of autonomy while EAS eligibility requirements (particularly the core eligibility concept of unbearable suffering) do not conflict with this principle of autonomy.