Relational Autonomy, Normative Authority and Perfectionism

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Relational Autonomy, Normative Authority and Perfectionism

Catriona Mackenzie

1. Introduction

In liberal democratic polities, the principle of respect for autonomy is widely

acceptedin theory, if not always in practiceas a cardinal moral value that

should guide political deliberation, public policy and practice, as well as our

attitudes toward our fellow citizens. Put simply, to respect autonomy is to respect

each persons interests in living her life in accordance with her own conception ofthe good. Underpinning the normative requirement to respect anothers autonomy

is the presumption that autonomy confers normative authority over ones life; the

authority to make decisions of practical importance to ones life, for ones own

reasons, whatever those reasons might be. Autonomous persons are presumed to

have the capacity, the right and the responsibility to exercise this authority, even if

they do not always exercise it wisely.

Despite widespread agreement about the importance of the principle of

respect for autonomy, its interpretation and application in particular contexts is

often contested. Such disagreements arise, in part, from conflicting value com-mitments within pluralist societies. But they also arise from substantive philo-

sophical disagreements about the conditions and capacities necessary for

autonomy, and the specific obligations on the part of other citizens and the state

that are entailed by the principle. Health-care contexts are often focal points for

such disagreements because illnessboth physical and mentalcan impair

agents autonomy, either temporarily or more permanently, and health-care deci-

sion making can also be compromised by preexisting impairments of autonomy.

In such contexts, when there might be good reason to doubt the agents normative

authority over her decisions, the questions of what conditions and capacities arenecessary for autonomy, and of what the normative requirement to respect

autonomy means, are often fraught.

The aims of this paper are twofold. My primary aim is to develop a weak

substantive, relational approach to autonomy that grounds an agents normative

authority over decisions of import to her life in her practical identity and in

relations of intersubjective recognition.1 My secondary aim is to defend a rela-

tional approach to the principle ofrespectfor autonomy and to argue that respect

for agents whose autonomy is impaired entails an obligation on the part of others,

for example, health-care providers, or state institutions, to promote the autonomycompetence of such agents.2 In this introduction I explain two problems arising

JOURNAL of SOCIAL PHILOSOPHY, Vol. 39 No. 4, Winter 2008, 512533.

Copyright the Author. Journal Compilation 2008 Wiley Periodicals, Inc.


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from the literature to which this paper is a response and outline the structure of the

argument in the rest of the paper.

The first problem arises from long-standing debates about autonomy withinmoral psychology concerning the basis of autonomous agents normative author-

ity over their decisions. A widespread intuition in the literature is that normative

authority derives in some way from the connection between autonomy and the

agents practical identity or evaluative first-person perspective.3 There are differ-

ent ways in which this intuition can be spelt out, for example, as identification

with ones will, reflective endorsement of ones desires and values, acting in

accordance with ones settled character or whole self, authenticity, and so on.4 But

a well-known problem with the different variants of this approach to normative

authority is that an agents practical identityor aspects of her identitymayhave arisen from oppressive social relationships, conditioning or control; her

practical identity may be shaped by false norms and beliefs and distorted values

arising from unjust social practices or political institutions; and it may incorporate

destructive affective attitudes toward herself, such as lack of self-respect or mis-

trust of her own judgments.5 These seem to be precisely the kind of factors that

compromise autonomous agency and hence an agents normative authority over

her decisions, her actions, and her will. The problem then is that just because an

agent acts in accordance with her settled character or reflectively endorses the

value commitments that define her practical identity, this is no guarantee that shedoes so autonomously.

The second problem arises from debates concerning what grounds the nor-

mative requirement to respect anothers autonomy. One compelling way of

grounding this requirement is via the notion of epistemic humility. Since I do not

know what it is like to be the other, or to be in her situation, I am obliged to

recognize her normative authority over her decisions. But the presumptive force of

the epistemic argument seems less evident in certain difficult cases, for example,

of addiction or mental illness, or even in some cases of oppressive social condi-

tioning when the agents practical identity does not seem to be fully her own. Suchcases therefore raise two questions. First, is the notion of epistemic humility the

best way to ground the principle of respect for autonomy? Second, in situations

where there might be good reason to doubt the agents normative authority over

her decisions, her actions or her will, what does respect for autonomy involve?

In the second section of the paper, I discuss two examples drawn from

health-care contexts to motivate and illustrate these problems. In my view rela-

tional approaches to autonomy, which hold that autonomy is a socially constituted

capacity, are best able to address these problems. Recently, however, John Christ-

man has expressed the concern that by deeming certain persons non-autonomous,some relational approachesthose that stipulate substantive not merely proce-

dural conditions for autonomymay be in danger of justifying quite extensive

forms of unwarranted paternalistic interference, thus undermining respect for

these agents autonomy.6 He also raises the more general worry that substantive

relational theories are implicitly committed to moral and political perfectionism.

Relational Autonomy 513


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In the third section of the paper I explain Christmans critique and respond to the

paternalism charge.

In the fourth section, I develop a weak substantive, recognition-based, rela-tional view, which aims to show how normative authority is both first personal and

thoroughly relational. On the view I develop, for an agent to have normative

authority over her decisions and actions it is not sufficient that her reasons for

action express her practical identity. In addition, she must also regard herself

as the legitimate source of that authorityas able, and authorized, to speak for

herself.7 I argue that such attitudes toward oneself can only be sustained in

relations of intersubjective recognition. On the basis of this view, I then defend the

claim that respect for autonomy involves an obligation to promote autonomy.

Finally, I respond to Christmans perfectionism charge. I accept that the kind ofweak substantive relational view I support is committed to some form of moral

and political perfectionism. However, I do not regard this as a decisive objection

to the view. Rather, I argue that a commitment to promoting autonomy entails a

perfectionist commitment to fostering and promoting the interpersonal and social

conditions necessary for its development and exercise.

2. Normative Authority and Epistemic Humility

In a landmark UK High Court decision in 2002, the presiding judge, DameElisabeth Butler-Sloss, decided in favor of an appellant, Ms. B, who had brought

a suit of unlawful trespass against a British hospital.8 Ms. B. was a forty-three-

year-old woman who had suffered a cervical spine cavernoma, a condition caused

by malformation of the blood vessels in the spinal cord, which left her a quad-

riplegic, completely paralysed from the neck down and requiring artificial venti-

lation. She underwent neurological surgery, which only resulted in a slight

improvement of her condition, enabling her to move her neck slightly. Ms. B. was

an educated and articulate woman who, prior to her illness, had been in charge of

a social work department in a hospital. She was not married and had no children.Disappointed by the failure of the surgery to result in any substantial improvement

to her condition, she requested that the ventilator be switched off, in accordance

with a Living Will she had executed eighteen months earlier upon suffering her

first spinal hemorrhage.

To determine whether Ms. B. was competent to make the decision to have

ventilation removed, she underwent three psychiatric assessments within a period

of two weeks, conducted by three different psychiatrists. She was judged compe-

tent by each assessment. After the last assessment, preparations were made to

switch off the ventilator. However, the day after the final assessment, the assessingpsychiatrist amended her finding and judged Ms. B. not competent. One of the

other psychiatrists then amended his decision, the ventilator was not switched off

and Ms. B. was prescribed anti-depressants. Two months later she was re-assessed

by the first psychiatrist who found her competent. Between that time and the time

of the hearing, seven months later, Ms. B. refused to participate in a weaning

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program, to see if her dependency on ventilation could gradually be reduced, and

continued to request that the ventilator be removed. Despite the fact that the

hospital and the treating doctors judged her to be competent during that wholeperiod, and despite a subsequent assessment before the hearing affirming this

finding, the case put by the hospital trust was that she was not competent.

After assessing the medical evidence, the psychiatric assessments and the

evidence of the patient, Dame Butler-Sloss found that Ms. B. was not merely

competent but that she was a most impressive witness. Ms. B.s reasons for

refusing a weaning program were that it would be likely to result in a slow and

painful death that would rob her of dignity and be distressing for her relatives. Her

reason for judging death to be preferable to a life spent on artificial ventilation,

with no prospect of recovery, and completely dependent on her carers with respectto even the most basic bodily functions, was that she would find such a life

intolerable. Ms. B. was clearly sufficiently rational and emotionally balanced to

understand the nature of her medical condition and her prognosis. She had

informed herself about the available treatment options, their potential side effects,

foreseeable risks, and probabilities of success. Further, there was no question

about whether she was making her decision under duress. In other words, the

conditions for informed consent were more than met in her case. The case of Ms.

B. thus seems to provide a compelling illustration of why there seems to be an

important connection between an agents practical identity and her right to exer-cise normative authority over decisions of practical import to her life.

The principle of respect for autonomy was central to Dame Butler-Sloss

decision in favor of Ms. B. Dame Butler-Sloss argued that the right to self-

determination with respect to ones life and ones bodily integrity trumps other

considerations, including the principle of beneficence or the medical teams judg-

ments about the patients best interests. Further, even if the medical team, as in this

case, felt deeply that to accede to Ms. B.s request would conflict with the values

embedded in their professional roles and self-conceptions, as involving responsi-

bilities to save life rather than end it, these concerns should not override thepatients decision. The judge argued that claims by the spinal specialist that Ms.

B. had insufficient information to refuse weaning because she had not experienced

a weaning program could not be sustained. What was really at issue was a clash

of values between some of the medical staff and the patient, and a failure on their

part to fully appreciate her perspective.

In her judgment, Dame Butler-Sloss grounds the principle of respect for

autonomy in epistemic humility, citing in particular Kim Atkins claim that

respecting patient autonomy involves recognition of the irreducibly subjective

character of our first-personal experience and of the differences that separate us assubjects.9 To quote Atkins:

Respect for autonomy is an acknowledgment of the limitations of our knowledge of other

people and a willingness to incorporate that understanding into our worldviews. When we

respect autonomy we dont simply observe anothers freedom from a distance, as it were;



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we accede to our fundamental fallibility and epistemological humility. It is in recognition

of the fact that we cannot experience from anothers perspective that we normally refrain

from judging what will make anothers life good for them.10

The principle of respect for autonomy, Atkins argues, gives rise to an obli-

gation to try to empathically engage with the others experience, to imagine what

the other persons situation is like for her, given her cares, values and concerns. In

the context of patient care, it requires carers and medical staff to try to understand,

from the patients perspective, her experience of illness, or of particular treatment

options:

Making way for the subjective character of experience isnotachieved by offering up more

facts for the person to face, it is achieved by allowing a place for the expression of a

persons perspective on the nature of their illness and the treatment they are being offered.11

It is clear from Ms. Bs evidence that she felt the hospital was denying her the

ability to express her first-person perspective on her situation and questioning her

normative authority to make judgments about her own life:

I felt that I was being treated as if I was being unreasonable by putting people in this

awkward position . . . I felt my path was being blocked and I was being pressurised to

accept this option [weaning], to quietly go away conveniently, even though at tremendouscost to me and my family . . . I felt that my rights were being eroded and that is not

something I tolerate really; it is not within my character to go along with that.12

The strength of an approach that grounds normative authority in the agents

first-personal experience, and respect for autonomy in an attitude of epistemic

humility, is that it underscores recognition of the others fundamental humanity. In

a health-care context, as Atkins points out, such recognition is particularly impor-

tant when patients have severe disabilities, or have been drastically physically

altered by illness, or when treatment involves gross violations of bodily integrity.In such situations, it can be very difficult for carers to identify and empathize with

the persons situation, to see her as a person with a distinctive perspective and

distinctive cares and concerns. However, I think it is important to distinguish

recognition of anothers humanity from respect for her autonomy, a distinction

that is somewhat blurred in Atkins analysis. For I can recognize anothers human-

ity and try to understand her subjective point of view while also acknowledging

that her normative authority over her will, her actions, and her judgment is

impairedfor example, because of mental illness, post traumatic stress, or inter-

nalized oppression. It is these kinds of cases that raise complicated ethical ques-tions in health-care and other contexts about the obligationsbeyond the

requirement to recognize the others humanitythat are entailed by respect for

autonomy.

A further problem with the subjective experience view is that our first-person

experience may be internally conflicted, raising the question of which of our



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motives, desires and values should count as reasons for us and have normative

authority over our wills. This question was a significant issue in the case of Ms. B.

At one point, after she had been deemed non-competent, Ms. B. apparentlyexpressed relief to the doctors that the ventilator had not been switched off and

agreed to consider going on a spinal rehabilitation program. The hospital trust

made much of this apparent ambivalence on Ms. B.s part, taking it as an indica-

tion that she was not competent and that her request for ventilation to be with-

drawn should not be taken as normatively authoritative for her, that is, as an

expression of her considered judgment. In her evidence, Ms. B. disagreed that she

was ambivalent or that she had changed her mind, explaining that she had agreed

to go on the rehabilitation program since the decision that she was not competent

ruled out what was for her the preferred course of action. She was neverthelessrelieved about not having to face immediately the stressful and difficult business

of saying goodbye to friends and family. Although the hospital trust therefore may

not have been justified in their assessment of Ms. B.s competence, the problem of

internal conflict and ambivalence suggests that the first-personal subjective char-

acter of experience is an insufficient basis on which to ground normative authority

and respect for autonomy.13

Reflective endorsement theories are motivated by the same underlying intu-

ition about the centrality of the agents first-person perspective, but such theo-

ries require more stringent conditions for autonomy, namely that the agentreflectively endorses her practical identity and the motivations and values that

guide her actions. Thus, in Christine Korsgaards version of the endorsement

view, although our situations and even aspects of our practical identities may not

be a matter of choice, and although we may experience internal conflict, through

processes of reflective endorsement, or rejection, these identities become nor-

mative for us and thereby acquire the authority to determine which of our

motives, desires, and values will count as reasons for us. It is through such acts

of endorsement that we resolve internal conflict, and integrate the various

aspects of our identity into a unified standpoint. Our reasons thus express ournormative self-conceptions: Autonomy is commanding yourself to do what you

think it would be a good idea to do, but that in turn depends on who you think

you are.14 Further, our obligations arise from what those self-conceptions

forbid, what decisions and actions they rule out as unthinkable for us: It is the

conceptions of ourselves that are most important to us that give rise to uncon-

ditional obligation. For to violate them is to lose your integrity and so your

identity, and to no longer be who you are.15 Integrity is a matter of living up to

standards that one has set oneself, standards that express ones conception of

who one is and what matters.Ms. B.s evidence seems to support a reflective endorsement view of norma-

tive authority. In reflecting on her situation and making decisions about her

treatment, she clearly thought deeply about her values and what mattered to her.

In her evidence, she described how difficult it had been for her as a Christian to

make a decision to have ventilation withdrawn. She said:



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I have questioned myself about this and it has challenged my integrity. It has been a very

difficult process to rationalise what I am doing in the context of my faith but I feel there is

no alternative, as I do not have a realistic hope of recovery. I have come to believe that

people die and become disabled and God does not always intervene.16

Despite the tragedy of her situation, Ms. B. was a somewhat ideal agent from

the point of view of a theory of autonomy. Now, however, let us consider the case

of a less ideal agent, call her Mrs. H.17 In contrast to Ms. B., Mrs. H. does not have

a sense of herself as having rights and does not reflect deeply on her practical

identity. Mrs. H.s drama is played out in an oncology ward where she has just had

a leg amputated below the knee as a last resort treatment for aggressive bone

cancer. Mrs. H. has lost her hair from chemotherapy and she is having to come

to terms with the prospect of permanent disability, perhaps eventually death,although her doctors are fairly confident that her short to medium term prospects

for survival are quite good. Her husband has recently left her because her disabil-

ity would be burdensome and he finds her and her condition an embarrassment.

Mrs. H.s practical identity involves a conception of herself that is governed by the

norms of traditional femininity that are taken as authoritative within her cultural

community, and her husbands abandonment has left her feeling worthless as a

person and without a reason to live. Mrs. H. informs her treatment team that she

wants to die and that she wants no further treatment if the cancer spreads to other

parts of her body.Agents such as Mrs. H. pose a challenge for endorsement accounts of nor-

mative authority because Mrs. H.s practical identity, that is, the self-conception

she endorses and the values that are authoritative for her, seems to be the product

of oppressive social relationships that undermine her ability to flourish. The

problems raised by this case are not merely of theoretical interest. Rather, given

reasonable doubts about the extent to which Mrs. H. exercises normative authority

over her will, how we answer the question of what is involved in respecting Mrs.

H.s autonomy has important implications for practice and policy in health-care

and other contexts. Among the practical and policy questions raised by this caseare the following: How should Mrs. H.s medical team respond to her expressed

preference not to receive further treatment? Should this preferencebased on the

reasons she cites and at this point in her treatmentbe taken as authoritative for

Mrs. H.? Is the medical team obliged, out of respect for patient autonomy, to

accede to her request? If the preference is not taken as authoritative, what options

are open to the medical team consistent with respecting her autonomy? Should

they try to change her mind? Would trying to change her mind be paternalistic?

Health-care professionals confront such questions on a daily basis and it is

incumbent on a philosophical theory of autonomy to provide some guidance inanswering them.

I aim to show that a weak substantive relational approach to autonomy is best

able to provide such guidance. On the view I wish to defend Mrs. H.s medical

team have an obligation not only to respect but also to promote Mrs. H.s

autonomy. Promoting Mrs. H.s autonomy requires attending, and appropriately



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responding to, the ways in which her socio-relational status as oppressed and

despised wife is relevant to an assessment of the normative authority of her request

to cease treatment. In my view, Mrs. H.s autonomy is compromised, and soacceding to her requestfor the reasons she cites and at this point in her

treatmentwould not in fact be consistent with respecting Mrs. H.s autonomy.

The appropriate response on the part of her medical team is to try to shift Mrs.

H.s perspective on her situation. But this approach need be neither paternalistic

nor coercive.

I develop the argument for this claim in the second half of Section 4. In setting

up the groundwork for this argument, in the following section I spell out in more

detail the theoretical difficulties for theories of autonomy raised by cases such as

that of Mrs. H., focusing in particular on the debate in the recent literature betweenJohn Christmans procedural approach to autonomy and Marina Oshanas strong

substantive relational approach.

3. Procedural Versus Substantive Relational Autonomy

Relational approaches to autonomy are motivated by two distinct, but inter-

related, claims. The first claim rejects the individualist assumptions aboutagency

implicit in mainstream conceptions of autonomy within bioethics, political phi-losophy, and moral psychology. Relational views are premised on a socially

embedded conception of agency and argue that an adequate theory of autonomy

must be based on recognition of the ways in which, as agents, our practical

identities and value commitments are constituted in and by our interpersonal

relationships and social environment. The second claim is that autonomy is itself

a socially constituted capacity, and because of this its development and exercise

can be impaired by abusive or oppressive interpersonal relationships and by social

and political environments characterized by oppression, injustice, and inequality.

The term relational autonomy is, however, an umbrella term that covers anumber of different views.18 There are differences of view, for example, about

whether autonomy is a social capacity mainly in the sense that social relationships

contribute to its development or whether it is social in a more constitutive con-

ceptual sense. There are also differences concerning whether the conditions nec-

essary for autonomy should be understood procedurally or substantively. In

Section 4, I will develop a weak substantive, conceptual version of the relational

view.

Although Christman sometimes represents procedural views as standing in

opposition to relational theories, his version of the procedural approach could wellbe characterized as relational, since in his recent work he acknowledges the

socially embedded, interpersonally constructed and historically situated nature of

the self and the role of these factors in the constitution of agency. 19 Briefly,

procedural theories are content-neutral. They hold that an agent is autonomous so

long as her values and motivations have been subjected to appropriate critical



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scrutiny, irrespective of their substantive content. Christmans version of the

procedural view distinguishes two kinds of conditions that are necessary for

critical reflection to count as adequate. The first are competency conditions thatspecify the competences and capacities necessary for autonomous reflection,

including minimal rationality, self-control, being able to access and understand

relevant information, motivational effectiveness (e.g. not being weak-willed,

impulsive, deluded), and so on. In line with relational theories, Christman sug-

gests that, in addition to these standard conditions, the competence conditions for

autonomy should be expanded to include capacities that are central to interper-

sonal relations, such as capacities for care, empathy, intimacy, and social coop-

eration. The second, authenticity, conditions specify what is required for an

agents values and motivations to be considered truly her own. Individualistconceptions of autonomy tend to understand authenticity in such a way that to be

autonomous an agent must somehow transcend her socialization, defining and

reflecting on her values and commitments free of social influence. Like relational

theorists, Christman rejects this conception of authenticity. He argues that any

adequate account of authenticity must recognize that not only is a persons

practical identity shaped by complex, intersecting social determinants and consti-

tuted in the context of interpersonal relationships; the process of reflection is

similarly shaped by these factors.

Procedural theories have been faulted on the grounds that the authenticity andcompetence conditions they stipulate would seem to allow agents who have been

thoroughly socialized by oppressive norms and relationships, such as Mrs. H., to

count as autonomous. Christman acknowledges that many endorsement, identifi-

cation or integration theories are vulnerable to this objection, since oppressed and

dominated agents may endorse aspects of their practical identities, or identify with

values, commitments, and desires, that arise from the oppressive conditions of

their lives. To deal with this difficulty, Christman stipulates two important further

constraints on procedural accounts.

The first is a historical, or non-alienation, constraint on the authenticityconditions for autonomy, which focuses attention on the historical processes by

which a person came to acquire a belief, desire or value commitment. 20 The

constraint specifies that a person is autonomous with respect to a belief, desire,

value commitment or decision only if, were she to reflect on the historical process

of its formation, she would not repudiate or feel alienated from it. The non-

alienation constraint differs from endorsement and identification views because

it does not require wholehearted identification, thus allowing that there are some

aspects of our identities that we neither repudiate nor identify with, but rather

accept. The non-alienation view does require, however, that to be autonomous aperson must be able to revise beliefs, values or commitments that she repudiates,

or from which she feels alienated, having reflected on the processes by which she

acquired them. Christman also adds a further constraint on the competence con-

ditions for autonomy, such that the capacity for reflection not be subject to various

distorting influences (psychological, social, or physical) that interfere with self-



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awareness. These might include overpowering emotions, being under the influ-

ence of hallucinatory drugs or other substances, being subject to physical or

emotional intimidation or manipulation, being depressed or mentally ill, or beingdeprived of exposure to educational or social opportunities to develop the capacity

to question, criticize, and reflect.21

I am not confident that the non-alienation constraint would be sufficient to

show why Mrs. H.s request to discontinue treatment is non-autonomous. For even

if she were to reflect on the historical processes by which her practical identity has

been shaped, it is not clear that Mrs. H. would repudiate or feel alienated from this

identity. Christman would argue, however, that Mrs. H.s decision is not autono-

mous because her capacity for reflection has been subject to various illegitimate

distorting influences. These might include distorting influences on her currentstatefor example, depressionas well as distorting influences in her past

historyfor example, not having sufficient educational or other opportunities to

develop the capacity for critical reflection, perhaps being subject to emotional or

physical intimidation by her husband, and so on.

Substantive relational theorists would argue, however, that Christmans

view does not provide a sufficient explanation of why Mrs. H.s autonomy is

impaired. However, different substantive theorists would provide different expla-

nations of the way in which Mrs. H.s autonomy is impaired. Strong substantive

theorists would locate the problem either in the content of Mrs. H.s beliefs andvalues or in the fact that, by virtue of her socio-relational status as subordinated

wife, Mrs. H. does not enjoy substantive independence.22 Marina Oshana, for

example, argues for the latter view and claims that the problem with procedural

approaches is that one can imagine an agent who satisfies Christmans more

stringent procedural constraints but reflectively endorses a life of submission to

oppressive relationships and social structures.23 To call such an agent autono-

mous, in Oshanas view, seems to violate our fundamental intuitions about

autonomous agency. One of Oshanas recent examples is the Taliban woman,

who once trained and practiced as a physician and lived an independent life, butwho has since chosen a life of complete dependence upon and subservience to

her husband and religious leaders.24 Suppose that her choice is made on the

basis of authentic and competent reflection, and that it is made under conditions

that do not curtail her capacities for autonomous reflection. Even if the external

constraints imposed by the Taliban regime effectively preclude her from choos-

ing otherwise, she endorses this choice as an authentic expression of her prac-

tical identity, thereby seeming to satisfy the conditions for autonomy on the

procedural view. Oshana argues that even if the Taliban woman exercises occur-

rent autonomy with respect to this particular choice, once she has made thischoice she has forfeited her global or dispositional autonomy.25 Her social situ-

ation, the institutions that perpetuate it, and her relationships with those around

her mean that effectively she is governed by others. For Oshana, then, autonomy

precludes a socio-relational status that subordinates an agent to the will of

others and thereby constrains her future choices.



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In response to this kind of view, which regards autonomy as constituted by

certain kinds of social relations, Christman charges more substantive variants of

relational views with internal inconsistency. The inconsistency charge is thatwhile a relational theory such as Oshanas emphasizes the importance of recog-

nizing the social embeddedness of agents, by insisting that some social relation-

ships are inimical to autonomy this view reverts to a kind of individualism, or

a highly idealized conception of individual autonomy, such that autonomous

agents must have certain value commitments and/or must be treated in certain

normatively acceptable ways.26 Oshanas strong substantive version of the rela-

tional approach does seem vulnerable to this criticism to the extent that on

Oshanas account to properly exercise her autonomy the Taliban woman seems to

be required to reject the very social relations in terms of which her practicalidentity is constituted.27 However, I would dispute the claim that substantive

relational views in general are vulnerable to the inconsistency charge. Substantive

relational views that criticize oppressive interpersonal relationships and social

structures on grounds other than those proposed by Oshana are not similarly

vulnerable to the inconsistency charge. In Section 4, I develop the view that

relationships and social structures that do not provide agents with the recognitive

basis necessary to sustain certain attitudes toward their own normative authority

are inimical to autonomy.

Christmans real concern, however, seems to be that substantive relationaltheories are committed to moral and political perfectionism. Christman states that

what he means by perfectionism is the view that values and moral principles can

be valid for a person independent of her judgment of those values and principles,

that is independent of the persons authentic embrace of them.28 It is worth noting

that this statement is ambiguous with respect to whether the persons authentic

embrace is occurrent or dispositional. As Oshanas example of the Taliban woman

shows, however, this distinction is crucial. For a person can authentically embrace

a value, or make a decision, at one point in her life that undermines her effective, or

global, autonomy. This point aside, however, I think what underlies Christmansobjection is a twofold concern that connects with the issues of normative authority

and respect for autonomy discussed in the previous section.

First, Christman is committed to the view that a value can only be normatively

authoritative for a person if she endorses it, or would endorse it, as authoritative for

her given her practical identity or first-person perspective. To the extent that

substantive relational theories such as Oshanas define autonomy in terms of other

values, for example, equality, regardless of whether or not a person endorses that

value, then such theories threaten to undermine the normative authority over ones

own life, and respect for others authority over their lives, that underpins the valueof autonomy itself.29 For this reason, he thinks, substantive relational views may be

in danger of undermining respect for the autonomy of those who, for religious or

ideological reasons, might authentically embrace traditional modes of life based on

hierarchies of status or subservience. Second, Christman is concerned that, by

potentially undermining respect for the autonomy of such persons, substantive



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relational views may be in danger of disenfranchising the perspectives of those who

are socially marginalized and discriminated against, excluding their voices from

public deliberation and lending support to various kinds of paternalistic interven-tion. According to Christman, to say of a person that she is not autonomous implies

that she does not enjoy the status marker of an independent citizen whose perspec-

tive and value orientation get a hearing in the democratic processes that constitute

legitimate social policy.30 For the remainder of this section of the paper I will

respond to this second concern. In the following section I will respond to the first

concern regarding perfectionism, the normative authority of the first-person per-

spective and respect for autonomy. In doing so, my aim is to develop a weaker

substantive relational approach than Oshanas.31

I think Christman is correct to raise concerns about social exclusion andpaternalism. Even though citizens might havede jurerights topoliticalautonomy,

that is, rights against the state to certain legal and political liberties, whether or not

they in fact possess or exercise high levels ofpersonalautonomy, we know that in

supposedly liberal societies certain social groups have been, and still are, socially

and politically disenfranchised and regarded as justifiably subject to unwarranted

and often coercive paternalistic treatment on the grounds that they are incapable

of self-determination. So Christman is correct to point to the potential dangers

attendant upon judgments that particular agents capacities for personal autonomy

are impaired or compromised. However, I would argue that this is a danger towhich any relatively stringent theory of personal autonomy, Christmans theory

included, must be alert. We have seen that an agent such as Mrs. H., even if she

authentically embraces her subservient socio-relational status, would be unlikely

to meet the competence conditions stipulated as necessary for autonomy on

Christmans view. So his procedural account is no less vulnerable than relational

theories to the concerns he raises. These concerns place an onus not only on

relational views, but also on his version of procedural theory, to ensure that a

theory of personal autonomy is not used to justify unwarranted paternalism or to

further politically disenfranchise the marginalized.It is also important to stress that it is a mistake to think of personal autonomy

as an all or nothing affair and to draw a sharp distinction between autonomous and

non-autonomous agents. As Diana Meyers has argued forcefully, if autonomy

requires a range of competences, then autonomy is a matter of degrees and

domains.32 An agent may be autonomous in some domains of her life, but not in

others. Further, some of her competences may be highly developed, while others

are significantly underdeveloped. In the case of citizens rights tode jurepolitical

autonomy, the threshold level of competence required ought to be minimal.

Agents who meet this minimal level of competence ought to be treated as politi-cally autonomous and entitled to enjoy the rights and liberties that it guarantees,

including freedom from the unwarranted paternalistic intervention of the state. To

characterize an agent as personally autonomous, however, involves attributing to

her capacities that go well beyond this minimal threshold, even if we accept that

personal autonomy itself is a matter of degree.



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Specifying what these capacities and competences are, however, is a separate

question from the question of how agents such as Mrs. H. should be treated if their

competences are underdeveloped in certain crucial respects or in certain domains.Christman seems to assume that the judgment that an agents autonomy is under-

developed or impaired in certain respects will inevitably lead to disrespectful

treatment of that agent. Now while he is correct to alert us to this danger, this

cautionary response is insufficient for grappling with the difficult practical ques-

tion that is raised by the case of Mrs. H. Namely, how can her medical team

respect Mrs. H.s autonomy if they have doubts about the normative authority of

her expressed preference not to have further treatment? This is a question that

Christmans procedural theory, no less than substantive relational views, must

address. Other than warning of the dangers of disrespect, however, Christmanprovides no guidance as to how this question should be addressed.

In addition, although Christman is right to alert us to the danger that the more

robust, stringent conditions necessary for personal autonomy could be used to

undermine citizensde jurerights to political autonomy and to justify unwarranted

paternalism, I think such conditions can also play the reverse political role. For

they can be used to explain how abusive or oppressive interpersonal relationships

and exclusionary social and political institutions are unjust; namely, because they

impair and restrict agents capacities to develop and exercise de facto personal

autonomy, even if they possess de jure rights to political autonomy.

4. Recognition, Respect, and Perfectionism

As we have seen, Christmans concern about the implicit perfectionism of

strong substantive relational theories, such as Oshanas, is that by defining

autonomy in terms of values that are held to be valid independent of the agents

practical identity, such theories potentially undermine both the agents claim to

normative authority over her life and respect for her autonomy. In this section I

respond to this concern. My response involves two main steps. First, with refer-ence to the examples of Ms. B. and Mrs. H., I propose an alternative and weaker

substantive relational approach than Oshanas, which grounds normative authority

in an agents attitudes toward herself. I also argue that these attitudes, and hence

an agents sense of herself as having a rightful claim to normative authority, are

based in intersubjective recognition. This argument shows why normative author-

ity is both first personal and thoroughly relational; and it shows how vulnerable

agents autonomy can be undermined by oppressive and abusive interpersonal

relationships and unjust social and political environments. It also provides the

basis for explaining the obligations involved in respecting the autonomy of vul-nerable agents, such as Mrs. H. Second, I argue that this kind of weak substantive

relational view is perfectionist in the sense that it claims that a just society has an

obligation to promote autonomy by ensuring that its basic social, legal, political,

and economic institutions provide the recognitive basis for its citizens to realize

their autonomy.



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A number of relational theorists, such as Paul Benson, Carolyn McLeod, and

Trudy Govier, have argued that exercising the competencies involved in autono-

mous reflection and deliberation requires having certain attitudes toward oneself,in particular, attitudes of self-respect, self-trust, and self-esteem.33 Iwanttodrawon

a version of this view proposed recently by Joel Anderson and Axel Honneth.34

Anderson and Honneth characterize the attitude ofself-respectas an affectively

laden self-conception that underwrites a view of oneself as the legitimate source of

reasons for acting.35 To regard oneself with appropriate self-respect is to think of

oneself as the moral equal of others, as having equal standing to have ones views

and claims taken seriously. When ones sense of self-respect is eroded it becomes

difficult to think of oneself as having the normative authority to view oneself as

a legitimate source of reasons for acting. Self-trustor basic self-confidence isthe capacity to trust ones own convictions, emotional responses, and judgments.

Anderson and Honneth argue, I think rightly, that this capacity is central to the kind

of reflexive self-interpretation involved in autonomous deliberation. Because our

practical identities are complex and dynamic, deliberating about what we ought to

do involves self-interpretationworking out which of our desires should constitute

reasons for us, which commitments are most important, which emotional responses

we should attend to, how to reconcile inner conflicts arising from the obligations of

different social roles, and so on. Lack of self-trust or basic self-confidence impairs

our capacity to understand ourselves and to respond flexibly to life changes. Theattitude ofself-esteem or self-worth is a fundamentally evaluative stance toward

oneself; it involves thinking of ones life, ones commitments, and ones undertak-

ings as meaningful, worthwhile, and valuable. Lack of self-esteem undermines

autonomy because if one does not think of ones life and ones activities as

worthwhile it is difficult to determine what to do and how to act.

The importance of these affective attitudes for autonomy helps clarify the

sense in which Ms. B. exercises autonomy and in which Mrs. H.s autonomy is

compromised. Ms. B. clearly regarded herself as a moral equal with a claim to

have her perspective taken seriouslyin fact it was this attitude that motivated herdecision to bring a legal suit against the hospital. Strange as it may sound, her

decision to have treatment withdrawn was motivated by an attitude of self-worth;

that is, by a sense that her life should be meaningful, worthwhile, and valuable,

and by a conviction that it could no longer continue to be so given her medical

condition. To grant normative authority to this conviction does not entail thinking

that everyone with Ms. B.s condition would similarly find their lives robbed of

meaning. But it does require understanding why, given her reflective self-

conception, it has normative authority for her. With respect to self-trust, although

Ms. B. obviously struggled with the decision to have treatment withdrawn becauseit challenged her practical identity as a Christian and her sense of integrity, the

decision exhibits a fundamental attitude of self-trust in her own convictions and in

the process of reflexive self-scrutiny she has undertaken.

In contrast, Mrs. H.s decision to discontinue treatment does not seem to be

underpinned by a strong sense of self-respect, self-trust or self-esteem. Mrs. H.



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does not have a sense of herself as a moral equal; her practical identity is rigid and

she does not have the kind of strongly developed sense of basic self-confidence

that might enable her to envisage a different future for herself than the one she hadanticipated; and she does not have a sense of her life as worth living in its own

right, independently of her relation to her husband. To avert possible misunder-

standing, let me be clear that I think Mrs. H.s situation is awful and that even the

most resilient, optimistic, and flexible person would experience difficulty coming

to terms with it. But I think the contrasting cases of Ms. B. and Mrs. H. show why

normative authority is bound up with an agents attitudes toward herself.

These cases also show why normative authority is thoroughly relational and

why an agents autonomy is intrinsically connected to her socio-relational

situationbecause these attitudes toward ourselves, and our sense of ourselves asable to claim normative authority with respect to our lives, can only be developed

and sustained intersubjectively. In other words, these attitudes are enmeshed in

interpersonal relationships and social structures of mutual recognition and it is for

this reason that our autonomy can be impaired by failures of recognition. Mrs.

H.s self-respect is eroded and she does not have a sense of herself as having

rights, even ifde jure her rights are protected, because this attitude has not been

developed and sustained in her relationship with her husband. Ms. B. does have a

strong sense of self-respect but is vulnerable to the hospital staffs refusal to grant

normative authority to her decision. Hence she must rely on the outcome of thecourt hearing to affirm that authority. For both, it is social relationships that do or

do not recognize their moral equality that determine whether the background legal

and political institutional framework that underpins their rights, is effective in

enabling their autonomy.

As Anderson and Honneth point out, citing object-relations theory, our

capacities for self-trust develop in the context of intimate interpersonal relation-

ships and are particularly vulnerable to abusive intimate relationships and bodily

violations. Mrs. H.s capacities for self-trust may have been eroded by subordi-

nation within her marriage or they may not have been well developed to beginwith, due to her upbringing. In either case, she will only be able to develop the

capacities for self-trust necessary for her to see herself as having a future through

other social relationshipsfor example, relationships with her children, relatives

or other members of her community; perhaps by participating in a cancer support

group; perhaps through the support of her carers.

With respect to self-esteem, a central issue in determining whether Mrs. H.

will be able to see her life as having value is whether within her social network

there are alternative socially available and recognized sources of self-esteem

around which she may be able to reconstruct her practical identity. She may nolonger be able to see herself as a wife, but she may be able to see herself as a

grandmother, or as a friend, or she may be able to put her considerable talents as

a seamstress to productive use, and so on.

Before addressing the question of what is involved in respecting Mrs. H.s

autonomy, I want to summarize the way in which this approach to normative



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authority is thoroughly relational while also upholding the intuition that normative

authority is grounded in an agents first-person perspective, practical identity, or

self-conception. First, to claim normative authority over her life an agent musthave a conception of herself as the legitimate source of that authority; as able, and

authorized, to speak for herself. What underwrites this self-conception, as we have

seen, are certain affective attitudes toward oneselfattitudes of self-respect, self-

trust, and self-esteem.36 However, to claim oneself as able and authorized to speak

for oneself is also to situate oneself as answerable and accountable to others. It is

thus to situate oneself in a complex network of intersubjective discursive norms

and practices involving mutual expectations and governed by social standards.37

These include, for example, such norms and practices as those involved in reason-

giving, in holding agents morally and legally responsible for their actions, ininterpersonal relations of care and concern, in participation in a social or political

community, and so on. Furthermore, our conception of ourselves as authorized to

speak for ourselves and our claims to normative authority are dependent upon the

recognition of others in the different spheres in which we make those claims: for

example, the interpersonal sphere, in our work lives, as citizens, as persons who

are both protected by and subject to the law, and so on. Because of this, the

affective attitudes that underpin our self-conceptions and the effectiveness of our

claims are also vulnerable to others failures, or refusals, to grant us appropriate

recognition. It should be emphasized that a persons sense of normative authorityis a matter of degrees and domains. Someone may have a strong sense of norma-

tive authority in some domains or spheres of her life but not in others. Thus a

woman may be a highly competent and effective teacher with a strong sense of

normative authority with respect to this sphere of her life, but quite content to let

her husband make all the financial decisions for their family.

Second, to claim authority a person must have a sense of who she is and of

what matters to her. And to have such a sense of herself she must engage, to some

degree, in activities of self-understanding and self-interpretation.38 However, our

sense of who we are is intrinsically bound up with, and vulnerable to, ourrelationships with others in all the different spheres of our lives. And self-

interpretation is thoroughly relational and socialit is only in and through our

relationships and interactions with others that we acquire sufficient self-

understanding to work out which of our desires should constitute reasons for us,

which commitments are most important, which emotional responses we should

attend to, how to reconcile inner conflicts arising from the obligations of different

social roles, and so on. Once again, self-understanding is a matter of degrees and

domains. For an agent rightfully to claim normative authority there is no require-

ment that she is either self-transparent or has privileged epistemic access to hermotivations, so long as the kinds of competence and non-alienation conditions

specified, for example, by Christman are satisfied.

How then should respect for Mrs. H.s autonomy be understood given this

recognition-based relational view? My claim is that respect for Mrs. H.s

autonomy involves a series of interconnected obligations on the part of the



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medical staff. First, it involves an obligation to recognize Mrs. H.s humanity; that

is, to treat her as someone, with a conception of herself and for whom certain

things mattersometimes patients might feel that even this basic kind of re-cognition is lacking in their encounters with the medical system. This is Atkinss

point. Second, it involves an obligation to try to understand Mrs. H.s subjective

perspective on her situation. Achieving this kind of understanding may be

challenginginevitably we find some peoples points of view much harder to

fathom than those of others, and differences in culture, language, ethnicity, gender,

religion, ability, life experiences, and so on, can constitute significant barriers to

understanding. But if Mrs. H. feels that her carers do not understand her and have

made no effort to do so then she is likely to feel that the medical team is just being

coercive if it continues to discuss treatment options with her. Third, because Mrs.H.s perspective is shaped by attitudes toward herself that undermine her flour-

ishing, respect for her autonomy involves an obligation not just to understand but

to try to shift her perspective and to promote her capacities for autonomy. This

involves trying to find ways to change Mrs. H.s attitudes toward herselfto try

to counter her sense of personal worthlessness, to promote her sense of self-

respect, to assist her to find reasons for living and to envisage a possible future in

which she would find her life meaningful. In other words, it involves both respect-

ing Mrs. H.s first-personal perspective while also providing her with the kind of

support, preferably with the assistance of family members and friends, that mayenable her to reevaluate and revise her perspective and her reasons for acting. This

is likely to be a slow and difficult process, requiring care and sensitivity on the part

of the treating health-care professionals, particularly given the other factors that

are likely to be in play. These include the asymmetry in power, knowledge, and

social status between her and her treatment team, differences in culture, level of

education, and life experience, all of which are likely to be compounded by her

increased vulnerability as a result of her illness. It is these asymmetries that can

give rise to paternalistic attitudes on the part of medical staff and a sense on the

part of patients that they are being coerced. But trying to shift Mrs. H.s attitudestoward herself need be neither paternalistic nor coercive, if handled sensitively

and prompted by a concern to promote Mrs. H.s autonomy. In fact I would argue

that good medical practice is underpinned by just this kind of interpretation of

respect for patient autonomy.

Does such a recognition-based, relational conception of respect for autonomy

involve some form of moral and political perfectionism? I think it does, but unlike

Christman I dont think this constitutes a decisive objection to the view and I think

Christmans procedural account may be closer to perfectionism than he acknowl-

edges. Moral perfectionism is the view that some goods, activities, and ways oflife, are not valuable and are not consistent with human well-being or flourish-

ing.39 This view is sometimes thought to entail value monism, the idea that the

good is singular and there is one kind of life that it is best for human beings to live.

However, this is a mistake. The kind of moral perfectionism to which I think a

weak substantive recognition-based view is committed is an autonomy-based



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perfectionism of the kind defended by Joseph Raz.40 On this view autonomy is not

just one goal or project a person might pursue or reject. Rather autonomy is an

important part of leading a good, valuable and flourishing human life.41

This formof autonomy-based perfectionism is quite consistent with value pluralism. In fact

Raz argues that it requires competitive value pluralism, since autonomy makes

possible choices between different and incompatible ways of life, each providing

different reasons for action and involving distinct virtues. Furthermore, in a

culture that supports autonomy moral conflicts between people who value differ-

ent goods and ways of life will inevitably arise. An autonomy-based perfectionism

does not therefore entail that autonomy is the only, or even a trumping, value. But

it does entail that ways of life that unjustly restrict the range of valuable options

open to some individuals, or groups, within a society are not valuable. I wouldsuggest that this is the real issue raised by Oshanas example of the Taliban

womannot whether or not her individual choice could ever be autonomous but

rather that in making that choice she has not only forfeited an important condition

for leading a flourishing life but is also supporting a way of life that requires all

women to make this forfeit. As Raz argues, the autonomous life depends not on

the availability of one option of freedom of choice. It depends on the general

character of ones environment and culture.42

Political perfectionism is the view that the state and other social institutions

have an obligation to protect and promote valuable goods and human lives. Thisview is sometimes thought to involve support for coercive and extensive gov-

ernmental interference with libertyindeed this concern about coercive inter-

ference seems to underlie Christmans worries about substantive relational

theories. Leaving aside the question of whether some forms of coercive state

interference with liberty may be justified (I think they arefor example, com-

pelling people to wear seat belts or motorcycle helmets), political perfectionism

need not involve support for coercive policies. Razs form of perfectionism, for

example, allows for coercive policies to prevent harms to ones own or other

peoples autonomy but rules out the use of coercion to discourage the choice ofnon-harmful but valueless opportunities or to promote particular moral ideals.

Ruling out coercive political means for promoting autonomy, however, does not

entail ruling out other political means for encouraging citizens to pursue valu-

able goalsfor example, incentive and reward schemes to encourage people

from disadvantaged social groups to pursue educational goals; health promotion

campaigns; funding subsidies for the arts, and so on. In fact an autonomy-based

perfectionism argues that the state and other social institutions have positive

duties to use such means in order to provide citizens with access to, and to

promote, an adequate range of valuable options. More broadly, following Ander-son and Honneth, I would argue that, as a matter of justice, the state and other

social institutions have duties to foster the kinds of social conditions that are

conducive to realizing citizens autonomy. This requires ensuring that social,

political, legal, and economic institutions provide the basis for mutual recogni-

tion and so do not leave some individuals and groups vulnerable to interpersonal



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relationships and social structures that impair or undermine the capacities and

affective attitudes necessary for autonomy.

In conclusion, although I accept that a recognition-based, relational approachto autonomy is committed to a form of moral and political perfectionism, I have

tried to show, contra Christman, that this commitment does not entail support for

using coercive paternalist means to promote autonomy. Rather, by emphasizing

the importance of autonomy for a valuable, flourishing life and the intrinsically

social character of autonomy, it highlights the positive obligations of social insti-

tutions to promote the autonomy of citizens by fostering the social conditions for

autonomy. The view I have defended thus holds that the promotion of autonomy

is a matter of social justice. Far from undermining respect for the autonomy of

vulnerable and marginalized persons and groups, its aim is to secure the socialconditions necessary for genuine respect.

Thanks to John Christman for extensive and very helpful comments on a much

earlier, and substantially different, version of this paper. For challenging and

helpful discussions of a later version of the paper, thanks to my colleagues in the

Philosophy Department at Macquarie University and to an audience in the Phi-

losophy Department at the University of Wollongong. Finally, I would like to

thank two anonymous reviewers for this journal for their very helpful comments

on the penultimate version of the paper.

Notes

1 I explain the difference between substantive and procedural theories of autonomy, and between strong

and weak substantive theories, in Sections 3 and 4 below. For further discussion of the procedural/

substantive distinction and of the differences between strong and weak substantive theories, see

Catriona Mackenzie and Natalie Stoljar, Introduction: Autonomy Refigured, in Relational

Autonomy: Feminist Perspectives on Autonomy, Agency and the Social Self, ed. Catriona Mack-

enzie and Natalie Stoljar (New York: Oxford University Press, 2000), 331. In a recent article,

Paul Benson provides an illuminating analysis of the differences between strong and weak

substantive relational theories. See Paul Benson, Feminist Intuitions and the Normative Sub-

stance of Autonomy, inPersonal Autonomy: New Essays on Personal Autonomy and Its Role in

Contemporary Moral Philosophy, ed. James Stacey Taylor (Cambridge: Cambridge University

Press, 2005), 12442.2 For related arguments to this effect see, for example, Carolyn Ells, Lessons about Autonomy from

the Experience of Disability, Social Theory and Practice, 27, no. 4 (2001): 599615; Carolyn

McLeod and Susan Sherwin, Relational Autonomy, Self-Trust, and Health Care for Patients Who

Are Oppressed, inRelational Autonomy, ed. Mackenzie and Stoljar, 25979; Carolyn McLeod,

Self-Trust and Reproductive Autonomy (Cambridge, MA: MIT Press, 2002); Susan Sherwin, A

Relational Approach to Autonomy in Health Care, in The Politics of Womens Health: Exploring

Agency and Autonomy(Philadelphia: Temple University Press, 1998).3 For different variants of this view see, for example, Christine Korsgaard, The Sources of Normativity

(Cambridge: Cambridge University Press, 1996), chap. 3; and Marilyn Friedman, Autonomy,

Gender, Politics (New York: Oxford University Press, 2003), chap. 1.4 For identification theories, see especially Harry Frankfurt, Freedom of the Will and the Concept

of a Person and Identification and Wholeheartedness, in Harry Frankfurt, The Importance of

What We Care About (Cambridge: Cambridge University Press, 1988); and Gerald Dworkin,



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The Theory and Practice of Autonomy (Cambridge: Cambridge University Press, 1988). For

different versions of the endorsement view, see especially Gary Watson, Free Agency, Journal

of Philosophy, 72 (1975): 20520; and Korsgaard, Sources. Different versions of the integrated

or whole self view have been proposed by Marilyn Friedman, Autonomy and the Split-LevelSelf, Southern Journal of Philosophy, 24, no. 1 (1986): 1935; and Nomi Arpaly and Timothy

Schroeder, Praise, Blame, and the Whole Self, Philosophical Studies, 93 (1999): 16188.

Authenticity conditions for autonomy have been proposed by John Christman and Diana

Meyers. For recent versions of Christmans view, see for example, Liberalism, Autonomy and

Self-Transformation, Social Theory and Practice, 27, no. 2 (2001): 185206; and Autonomy,

Self-Knowledge and Liberal Legitimacy, in Autonomy and the Challenges to Liberalism, ed.

John Christman and Joel Anderson (Cambridge: Cambridge University Press, 2005), 33057.

Meyers most extended discussion is in her Self, Society and Personal Choice (New York:

Columbia University Press, 1989).5 See especially Paul Benson, Autonomy and Oppressive Socialization,Social Theory and Practice,

17 (1991): 385408. See also Mackenzie and Stoljar, Autonomy Refigured, in Relational

Autonomy, ed. Mackenzie & Stoljar, 331.6 John Christman, Relational Autonomy, Liberal Individualism and the Social Constitution of Selves,

Philosophical Studies, 117 (2004): 14364.7 In Feminist Intuitions, Paul Benson develops a weak substantive relational view that similarly

grounds autonomy in agents attitudes towards their own authority to be answerable for their

reasons for action. Benson argues that there is a potentially wide, largely unmapped expanse of

theoretical terrain that stretches between strong substantive theories and strictly neutral ones

(Benson, Feminist Intuitions, 136). My aim in this paper is to contribute to the theoretical project

of mapping out this terrain.8 The Case of Ms. B. versus an NHS Hospital Trust, UK High Court of Justice, Family Division,

22 March 2002. Dame Elisabeth Butler-Sloss judgment can be found at: http://www.

courtservice.gov.uk/judgmentsfiles/j1075/B_v_NHS.htm.9 Kim Atkins, Autonomy and the Subjective Character of Experience,Journal of Applied Philosophy,

17, no. 1 (2000): 7179.10 Atkins, Subjective Character, 75. The epistemic issues highlighted in Atkins discussion of the

centrality of first-person perspectives to the concept of patient autonomy are also highlighted by

Marilyn Friedman in her discussion of the appropriate responses by professional care-givers to

victims of domestic violence. See Friedman,Autonomy, Gender, Politics, chap. 7.11 Atkins, Subjective Character, 76.12 Statement from Ms. B, quoted in the judgment of Dame Elisabeth Butler-Sloss, http://www.

courtservice.gov.uk/judgmentsfiles/j1075/B_v_NHS.htm, 12.13 Internal conflict and ambivalence may not always compromise autonomy. For an agent may self-

reflectively acknowledge ineradicable tensions between different aspects of her practical identity,

arising for example, from different social role expectations or different, intersecting social group

identities. For further discussion of this issue, see, for example, Paul Benson, Taking Ownership:

Authority and Voice in Autonomous Agency, in Challenges to Liberalism, ed. Christman and

Anderson, 10126; Diana Meyers, Intersectional Identity and the Authentic Self?: Opposites

Attract, inRelational Autonomy, ed. Mackenzie and Stoljar, 15180; Marina Oshana, Autonomy

and Self-Identity, in Challenges to Liberalism, ed. Christman and Anderson, 7797.14 Korsgaard,Sources, 107.15 Ibid., 102. There are resonances between Korsgaards claim that obligations arise from what our

practical identities forbid and Frankfurts view that the unthinkable marks the boundaries of thewill. See Frankfurt, Rationality and the Unthinkable, inThe Importance of What We Care About

(Cambridge: Cambridge University Press, 1988). For a helpful discussion of Frankfurts notion of

the unthinkable, see Gary Watson, Volitional Necessities, inThe Contours of Agency: Essays on

Themes from Harry Frankfurt, ed. Sarah Buss and Lee Overton (Cambridge, MA: MIT Press,

2002), 12959.

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16 Statement from Ms. B, quoted in the judgment of Dame Elisabeth Butler-Sloss, http://www.

courtservice.gov.uk/judgmentsfiles/j1075/B_v_NHS.htm, 13.17 The case of Mrs. H. is based on a real clinical case, as described to me by a physician who expressed

some scepticism about whether the notion of respect for patient autonomy can really aid clinicaldecision making in difficult situations.

18 For further discussion see Mackenzie and Stoljar, Autonomy Refigured.19 See especially Christman, Self-Transformation; Liberal Individualism; and Liberal Legiti-

macy. Another relational theorist who adopts a procedural approach is Friedman in Autonomy,

Gender, Politics.20 The historical constraint is first discussed in Christman, Autonomy and Personal History, Canadian

Journal of Philosophy 21 (1991): 124. In his more recent work, cited at note 19 above, he

formulates this constraint in terms of non-alienation.21 See especially Christman, Self-Transformation and Liberal Individualism.22 For a strong substantive theory that imposes constraints on the contents of autonomous agents

beliefs and values, see Natalie Stoljar, Autonomy and the Feminist Intuition, in Mackenzie and

Stoljar, Relational Autonomy, 94111. For a strong substantive theory that imposes constraints

on autonomous agents socio-relational status, see Marina Oshana, Personal Autonomy and

Society, Journal of Social Philosophy 29, no. 1 (1998): 81102; How Much Should We Value

Autonomy?,Social Philosophy and Policy 20, no. 2 (2003): 99126; andPersonal Autonomy in

Society(Aldershot, UK: Ashgate, 2006), chap. 2.23 Oshana, Personal Autonomy and Society and How Much Should We Value Autonomy?24 Oshana, How Much Should We Value Autonomy?25 Oshanas argument draws on Robert Youngs distinction between occurrent and global or

dispositional autonomy, in Young, Personal Autonomy: Beyond Negative and Positive Liberty

(Netherlands: Croom Helm, 1986).26 Christman, Liberal Individualism, 151.27 For a related criticism of Oshanas approach, see Diana Meyerss review ofPersonal Autonomy in

Society, Hypatia 23, no. 2 (2008): 2026.28 Christman, Liberal Individualism, 152.29 Christman claims that autonomy has value because it constitutes, in part, the human agency

and capacity for authentic choice that grounds respect for ourselves and other persons, Ibid.,

153.30 Ibid., 157.31 In Chapter 5 of Personal Autonomy in Society, Oshana develops her own response to Christmans

criticism that her view is too restrictive and seems to invite unwarranted paternalism. Since my aim

is to develop a different kind of substantive relational view than Oshanas, it would take mebeyond the scope of my concerns here to elaborate the differences between Oshanas response to

Christman and the response I develop in the text below.32 Meyers,Personal Choice. Joseph Raz also insists that autonomy is a matter of degree. See Joseph

Raz,The Morality of Freedom(Oxford: Clarendon Press, 1986).33 Paul Benson, Free Agency and Self-Worth, Journal of Philosophy 91 (1994): 65068; Taking

Ownership; and Feminist Intuitions; Carolyn McLeod,Self-Trust and Reproductive Autonomy;

Trudy Govier, Self-Trust, Autonomy, and Self-Esteem, Hypatia8 (1993): 99120.34 Joel Anderson and Axel Honneth, Autonomy, Vulnerability, Recognition, and Justice, in Chal-

lenges to Liberalism, ed. Christman and Anderson, 12749.35 Ibid., 132.36

It must be acknowledged that these attitudes, and an agents sense of normative authority, may notalways be justified. For example, an adolescent may have a stronger sense of trust in her own

judgment than is warranted. I cannot address here the complex issue of what counts as appropriate

self-trust, but I would argue that norms of appropriateness are intrinsically social but also

contestable.37 For further discussion, see Benson, Taking Ownership.

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38 Oshana also emphasizes the importance for autonomy of having some degree of self-reflective

awareness of ones self-conception, in Oshana, Autonomy and Self-Identity.39 For a helpful overview of the issues raised by both moral and political perfectionism, see Steven

Wall, Perfectionism in Moral and Political Philosophy, in Stanford Encyclopedia of Philosophy,ed. Edward Zalta,http://plato.stanford.edu/entries/perfectionism-moral/. First published 13 Feb,

2007.40 Joseph Raz, The Morality of Freedom, and Ethics in the Public Domain: Essays in the Morality of

Law and Politics (Oxford: Clarendon Press, 1994).41 It is not clear whether Raz is committed to the view that autonomy is a transcendent value, that is,

necessary for leading the best life one can, or to the view that autonomy is a contextual value,

necessary for leading the best life one can in a modern, liberal democratic state. For a more

detailed discussion, see David McCabe, Joseph Raz and the Contextual Argument for Liberal

Perfectionism, Ethics, 111, no. 3 (2001): 493522. It is beyond the scope of this paper to

investigate the implications of these different interpretations of Razs view; however, the argument

developed in this paper depends only on the contextual interpretation.42 Raz, The Morality of Freedom, 391.

http://plato.stanford.edu/entries/perfectionism-moralhttp://plato.stanford.edu/entries/perfectionism-moral

Relational Autonomy, Normative Authority and Perfectionism

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