some cultural, and some to do with the success of particular models of analysis
within bioethics.
In the latter part of the twentieth century an emphasis on individual autonomy
sat happily with the prevailing political ethos which saw the breakdown of tradi-
tional socialism and communism, and a wide-scale shift towards market driven
libertarianism. In a political climate which favoured individualism over
collectivism and personal effort over state welfare it is hardly surprising that
autonomy was what the advertising executives call a positive buzz word. The
dominance of Northern European and American culture with its emphasis on such
notions as privacy, individual initiative and consumerism led to the individual
being appealed to and represented in most areas of their life as a potential
exerciser of choice. To be autonomous was to fit into the picture of what it meant to
be an effective and successful member of society [5].
In terms of professional culture within the health service the pendulum had
swung against medical paternalism, and a general attack on the medical model of
care led to a recharacterisation of the classic relationship between doctor and
patient, and doctor and nurse. Instead of the all powerful doctor and his 6sic)
handmaid the nurse ministering to the sick patient, the relationship between
carers and patient was now presented as a contractual model with each party
having rights and duties. The patient became the client, and in some senses at least
became indistinguishable from any other type of consumer. The nurse was
encouraged to develop her own professional autonomy and where necessary act to
promote that of the patients if it was under threat from the doctor [6].
Given its high profile within both academic and professional literature it is
important to be clear about what one means by the term autonomy, and what one
assumes is involved in paying it due respect. To quote Beauchamp and Childress
[7], `respect for the autonomous choices of other persons runs as deep in common
morality as any principle, but little agreement exists about its nature and strength
or about specific rights of autonomy'.
Here are just a few frequently quoted accounts of what it means to be autono-
mous, demonstrating the range of ideas theorists have seen in the concept:
`I am autonomous if I rule me and no one else rules I.' [8]
`A person is autonomous to the degree that what he thinks and does cannot be
explained without reference to his own activity of mind.' [9]
`[A]cting autonomously is acting from principles that we would consent to as
free and equal rational beings.' [10]
`I and I alone am ultimately responsible for the decisions I make and am in that
sense autonomous.' [11]The word autonomy is derived from the Greekautosandnomia,and means self
rule. Most definitions remain true to this root, and include ideas of self govern-
ance, sovereignty, control and quite often independence. To be autonomous is to
be in control of your life in a very particular way, referring as it does to rationality
as opposed to mere freedom. Responsibility is quite appropriately seen as a closely
related concept and the autonomous person may be free or unfree to act upon their
autonomous choices, but in doing so must accept some responsibility for the
consequences [12]. More extreme definitions sometimes appear to suggest that
Consent and the Capable Adult Patient 123