underlying illness affects a person's autonomy, but the fact that it is an illness
rather than a chosen way of life will be seen to make a difference. Just as the
substance abuser's or alcoholic's first-order desire for their drug impairs their
autonomy, the person with an eating disorder is disproportionately determined by
the relationship they have with food. Having said this, it is important to remember
that even those who find aspects of their life dominated by illness or addiction
might remain capable of making autonomous choices in other areas of their life.
One of the reasons that respect for autonomy and the prioritising of consent are
seen as important in the context of health care delivery is because both are seen as
acorrective for paternalistic attitudes. However, paternalism can be understood in
anumber of ways and it is at least possible that some forms of paternalism are
morally acceptable in certain circumstances. Hard paternalism is defined as acting
or choosing on another's behalf because you feel qualified to do so, and because
you believe it to be in their best interest that you do so irrespective of their past or
future consent, and irrespective of their belief that they are perfectly able to act on
their own behalf. Such paternalism is difficult to justify, and by underlining the
importance of acquiring consent even in difficult circumstances we protect against
paternalistic practices of this type being widespread.
Soft paternalism on the other hand involves acting on another's behalf and in
their best interest because you believe them to be temporarily unable to exercise
their autonomy, which could translate into a temporary inability to participate in
the consenting process. In such cases one might protect against the unacceptable
excesses of paternalism by introducing another notion of consent often referred to
as hypothetical consent. In such a case one might choose in the patient's best
interest and with reference to ideas about what they might or might not consent to
were they able to participate. Thus we intervene only because we consider them to
be unable to consent for themselves, and in deciding for them we attempt to make
achoice that they will ultimately accept.
7.7.2 Insufficient autonomy to consent
The question of how to proceed morally in the absence of consent is a difficult one.
Various routes have been explored, for example the use of proxies, such as in the
case of parents choosing for children [17]. However, proxy consent is not
unproblematic, for example one has to decidehowto decide for another. One
could attempt to choose as they would have done had they been able to do so, or
one could try instead to choose in their best interests. Neither route is easy.
Advance directives have been discussed frequently in recent years. Although
their legal status remains ambiguous, the ethical principles behind such docu-
ments are clear, in that they attempt to allow an individual to give or withhold
consent at a point at which their lack of capacity would usually exclude them.
More usually they take the form of pre-stated treatment refusals, and as such their
enforcement is dependent on the patient finding themselves in the clinical
situations they have anticipated. In the case of organ donorship however, they take
the form of a permission to act upon the person's body after death. In both cases
problems might arise if the wishes of the person who signed the document conflict
with those later responsible for their care.
Consent and the Capable Adult Patient 125