This week, I'm having a special seminar on Autonomy, heteronomy and inequality at the Annual ESPMH Conference, this time in Zagreb.
Abstract of the seminar:
For years now, research on inequalities in health demonstrates the importance of social determinants in health outcomes. Contrary to that, public debates on health offer us a picture as if the only problem left in healthcare is how to empower individual patients so they would be able to make the right and autonomous choices and lead a healthy lifestyle. Next to that, in many countries the pursuit of a healthy lifestyle has or is expected to become a criterion in the allocation of healthcare services.
One of the crucial questions is what could be the consequences of this evolution for health care policy for individuals and for society in general? If we consider individuals as autonomous and regard the way they live as largely a matter of their own free choice, would it then not be “logical” to hold patients personally responsible for making (un)healthy life style choices, when they try to obtain insurance or enter healthcare facilities? And if the individuals are unwilling to change their risky behavior, could they then also be denied health care services?
As the idea of patient empowerment runs the risk of reducing health problems to the responsibility of the autonomous individual, we want to take into care a broader perspective. The myth of the independent autonomous individual taking rational decisions about his health and lifestyle, is indeed a myth. All of us are related to an outer world, to family and networks of friends, etc. We will call that heteronomy: the dependency of an individual to circumstances (determinants, social context) transcending its own choices. Heteronomy differs from paternalism. Judging from outside on what is the best in our interest, is exactly what the paternalist does: exercising over an individual’s choice for a particular way of living, or punishing the individual for not having the right lifestyle or for not having made the right choices.
Starting from the importance of social determinants, of course, the goal of healthcare should be to decrease heteronomy in people’s lives by offering them the chances to be able to live their life according to the choices they personally have made. The more we can increase autonomy, the better off we will be and the better for our health. At the same time, we should be fully aware that this goal will never be realized. The current ideal of the autonomous, self-monitoring patient, does not account for most people and the reality is way more complex than individuals making rational choices.
Consequently, more and more patient autonomy is understood as a thick concept or as ‘relational autonomy’ leaving the idea of fully independent beings behind. People can be empowered to make the choices they prefer, but we should also reflect upon the conditions how heteronomy hinders them from making the choices they want to or healthcare expects them to do. This reflection should prevent us from stepping back into paternalistic scenario’s, knowing what’s in the best interest for the people and punishing them if they do not make the ‘right’ choices. Although patient autonomy should always be our goal, the agency of autonomy never stands on its own.
In this special seminar, we present papers on ongoing research in phenomenology, on participation in screening programs, on health in equality and how these might put patient autonomy under pressure. Next to the papers, we will have a roundtable debate on autonomy and health inequality.