respecting autonomy without disclosing information

RESPECTING AUTONOMY WITHOUT DISCLOSING INFORMATION

TOM WALKER

Keywordsinformed consent,autonomy

ABSTRACTThere is widespread agreement that it would be both morally and legallywrong to treat a competent patient, or to carry out research with a compe-tent participant, without the voluntary consent of that patient or researchparticipant. Furthermore, in medical ethics it is generally taken that thatconsent must be informed. The most widely given reason for this has beenthat informed consent is needed to respect the patient’s or researchparticipant’s autonomy. In this article I set out to challenge this claim byconsidering in detail each of the three most prominent ways in which‘autonomy’ has been conceptualized in the medical ethics literature. I willargue that whilst these accounts support the claim that consent is neededif the treatment of competent patients, or research on competent individu-als, is to respect their autonomy, they do not support the claim that informedconsent is needed for this purpose.

INTRODUCTION

There is widespread agreement that it would be bothmorally and legally wrong to treat a competent patient,or to carry out research with a competent participant,without the consent of that patient or research partici-pant. In order for consent to do its work it is also gener-ally agreed that the consent given must be voluntary.Indeed, English Law has until fairly recently held that it isonly if this requirement is not met that the apparentconsent does not constitute ‘true consent’.1 Importantly,on this legal account the information disclosure require-ments associated with the need to obtain consent wereminimal, essentially comprising information about whatin general terms was to be done.2 In this English law atthat time differed from the position that has traditionallybeen taken within medical ethics.3 Medical ethicists have

generally held that for consent to be ethically effective itneeds to be informed. Exactly what information is neededfor consent to count as informed is a matter of consider-able dispute, but would generally be taken to includeinformation about things like the risks and benefits ofa procedure. Fortunately we do not need to enter thisdispute here. In what follows I will take any accountaccording to which patients or research participants mustbe given information over and above information aboutwhat in general terms is to be done to them as one requir-ing informed consent. According to all such accountsfailure to disclose information to patients or potentialresearch participants (and perhaps to ensure that thisinformation is understood)4 would mean that evenwhere consent has been obtained, treating the patient orinvolving the participant in research would still be prima

1 See Sidaway v Royal Bethlem Hospital [1984] 1 All ER 1018 at 1026.2 See Chatterton v Gerson [1981] 1 All ER 257.3 It was also different from the law in other countries, such as theUnited States, where informed consent was required much earlier (seeS.F. Kurtz. The Law of Informed Consent: From ‘Doctor is Right’ to‘Patient has Rights’. Syracuse Law Rev 2000; 50: 1243–1260).

4 Accounts of what is needed for informed consent differ as to whetherdoctors and researchers are required merely to disclose information orwhether they are also required to ensure that it is understood. For mypurposes here we can ignore this distinction. My argument will be thattreating someone, or including them in one’s research, where they lackinformation (with the exception of information about what is to be doneto them) does not constitute a failure to respect their autonomy.

Address for correspondence: Dr. Tom Walker, Centre for Professional Ethics, Keele University, Keele, Staffordshire ST5 5BG, UK. Email:[email protected] of interest statement: No conflicts declared

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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/j.1467-8519.2012.01971.x

© 2012 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

facie wrong because one would be acting without theirinformed consent.5

Whilst this position has come under pressure in recentyears,6 within contemporary medical ethics the mostwidely held reason for thinking that informed consent isneeded is that treating a patient or involving a participantin research without their informed consent would be afailure to respect their autonomy. In this article I want tochallenge this account. I will argue that whilst consent isneeded in order to respect autonomy, the requirement torespect autonomy does not generate a requirement toobtain informed consent. In order to do this it is impor-tant to be clear about what is meant by ‘autonomy’ here.Whilst this is a highly contested term with multiple mean-ings,7 in debates about informed consent it has generallybeen used in one of three ways – as referring to autono-mous choices, as referring to the capacity for autonomy,or as referring to autonomy as sovereignty.8 Because it isthese accounts of autonomy that have been taken toground the requirement for informed consent I will focuson them here – starting in the next section with the ideathat it would be wrong to treat a patient, or to involvesomeone in research, without their informed consentbecause this would be to fail to respect their autonomouschoices. My argument will be that on none of these threeaccounts does an obligation to respect autonomy (and Iwill assume for the purposes of this article that such anobligation exists) generate a requirement that doctorsand researchers disclose information beyond telling theirpatients and research participants what is to be done.Hence, the standard reason for thinking that informedconsent is required in medicine and research is mistaken.

1. RESPECT FOR AUTONOMOUSCHOICES

In their influential account of the relationship betweenautonomy and informed consent, Tom Beauchamp andJames Childress argue that informed consent is needed ifwe are to respect patients’ autonomy, and specificallystate that ‘autonomy’ here relates to autonomous choices

rather than to autonomous agents.9 The relevant choicehere is the choice about whether or not to have treatment,or to take part in research. The individual’s consent ordissent is simply the expression of this autonomouschoice. As such, on this type of account it would bemisleading to say that informed consent is needed inorder to respect the patient’s or research participant’sautonomy. It is rather that where consent expresses anautonomous choice it ought to be respected because thechoice is autonomous. One issue that arises here is aworry about the grounds for thinking that a choiceshould be respected just because it is autonomous.10

Fortunately for our purposes here we do not need toenter this debate. As stated above my concern is withwhat follows if we assume that autonomy ought to berespected.

The most natural way of thinking about the require-ment to respect someone’s choice (autonomous or not) isthat it relates to what we should do in response to theirchoice. For example, if a patient were to make an autono-mous choice not to have treatment, giving them thattreatment would be a failure to respect that choice.Things are less clear, however, where the person con-cerned has not made an autonomous choice. Considertwo examples. In the first a patient who lacks sufficientunderstanding to make an autonomous choice aboutwhether or not to have treatment refuses it.11 Treatingthis patient does not seem to involve a failure to respecthis autonomous choice – he has not made an autonomouschoice and so treating him cannot be a failure to respectsuch a choice. In the second a person is included in aresearch study without their knowledge. Because they donot know about the research they have not made a choiceabout whether or not to participate, and hence have notmade an autonomous choice not to take part. As in thefirst case involving this person in the research does notappear to involve a failure to respect their autonomouschoice because there is no autonomous choice to respect.In both these examples the person concerned has notgiven informed consent. However, as we have seen, treat-ing them or involving them in research would not involvea failure to respect their autonomous choices. Because ofthis, the requirement to respect a person’s autonomouschoices does not generate a requirement to obtain theirinformed consent before providing treatment or carryingout research. One could carry out that treatment orresearch in the absence of their informed consent without

5 This is not to say that it would be morally wrong all thingsconsidered. There may be situations in which treatment or research isjustifiable in the absence of consent.6 O. O’Neill. Some Limits of Informed Consent. J Med Ethics 2003; 29:4–7; J.S. Taylor. Autonomy and Informed Consent: A Much Misun-derstood Relationship. J Value Inq 2005; 38: 383–391; N.C. Mansonand O. O’Neill. 2007. Rethinking Informed Consent. Cambridge:Cambridge University Press.7 G. Dworkin. 1988. The Theory and Practice of Autonomy.Cambridge: Cambridge University Press: 6.8 J. Wilson. Is Respect for Autonomy Defensible?. J Med Ethics 2007;33: 353–356: 353.

9 T.L. Beauchamp & J.F. Childress. 2009. Principles of BiomedicalEthics (6th edn). Oxford: Oxford University Press: 100.10 Manson and O’Neill, op. cit. note 6, pp. 18–22.11 Whilst most philosophical accounts of autonomous choices andactions do not contain any requirement that such choices or actions bemade with understanding, that of Beauchamp and Childress does and itis this account that has proved influential in medical ethics (Beauchampand Childress, op. cit. note 9, p. 101).

2 Tom Walker

© 2012 Blackwell Publishing Ltd.

this being a failure to respect their autonomy (whereautonomy relates to autonomous choices).

The above argument rests on the idea that therequirement to respect autonomy is only a requirement torespect the actual autonomous choices that someonemakes. Because of this it does not impose any obligationswhere a person has not made, or is not in a position tomake, an autonomous choice. This however may movetoo quickly. According to Beauchamp and Childress,respect for autonomy has a positive aspect. This meansthat it requires not just respectful treatment but also,‘actions that foster autonomous decision making’.12

Given that on this account a decision is only autonomousif it is made with sufficient understanding, this positiveaspect provides support for the idea that doctors andresearchers need to provide information to patients andresearch participants in order to respect their autonomy.Providing this information would be required by the needto foster autonomous decision making, and this in turn isneeded in order to respect autonomy. If this is right, thenthe requirement to respect autonomy would (contrary towhat was stated earlier) places obligations on doctorsand researchers whose patients or potential researchparticipants have not made an autonomous choice.

For the idea that respect for autonomy requires foster-ing autonomous decision making to be plausible, it mustbe restricted to cases where there is a prior need for anautonomous decision to be made. There cannot be arequirement that my doctor provide me with informationthat is relevant to making an autonomous decision abouttreatment for a condition I do not have. The idea insteadseems to be that where I need to make a decision aboutwhat to do, but lack relevant information, my doctorought to provide that information. That way I will be ina position to make an autonomous choice (or to make amore autonomous choice). Furthermore, I will also onlybe in a position to give informed consent if this informa-tion has been provided. That is, it is only if my autonomyhas been respected (in the sense of fostering autonomousdecision making) that I will be in a position to make aninformed choice about whether to have treatment or toparticipate in research. On this account, then, doctorsand researchers ought to respect autonomy in order toensure that their patients and research participants are ina position to give informed consent.

This, however, is very different from the requirementthat informed consent must be obtained before treatmentor research in order to respect patients’ or researchparticipants’ autonomy. To see this, consider a potentialresearch participant who does not know anything aboutthe research proposed, and where the research could bedone without the participant’s knowledge. If there were aprior requirement that the participant provide informed

consent before taking part in the research, this would (onthe account outlined above) give a reason for providinghim with information about the project. Similarly, ifthere were a prior reason for thinking that he needs tomake an autonomous choice about whether or not totake part, then again respect for autonomy would requirethat information be given to him. However, the need torespect his autonomous decisions generates neither arequirement to obtain informed consent, nor a require-ment to obtain an autonomous decision from himabout whether to participate. As such, in this case itwould appear that a concern for respecting the autono-mous choices of research participants does not generate arequirement to provide relevant information to them.

The problem with the idea that informed consent isrequired in order to respect autonomous choices thatwe are considering here stems from the fact that sucha requirement is silent about our obligations wheresomeone has not made an autonomous choice. Morespecifically, it does not show why it would be wrongeither to treat such a person, or to involve them as aparticipant in our research, without their informedconsent. Where someone has made an autonomous deci-sion not to have treatment (or not to participate inresearch) going against their decision would be a failureto respect their autonomous choice. But where they havenot made an autonomous choice about whether or not tohave treatment (or to participate in research), providingthat treatment (or involving them in that research)without their consent would not involve a failure torespect their autonomous choice. This is simply becausein these cases they have not made an autonomous choicethat would be disrespected by acting in these ways.Because the requirement to respect autonomous choicesdoes not in itself mean that one has to obtain an auto-nomous decision, this requirement also does not generatean obligation to provide information as a way to fosterautonomous decision making. For these reasons therequirement to respect patients’ and research partici-pants’ autonomous choices does not, on its own, generatea requirement to obtain informed consent before onecarries out treatment or research.

2. AUTONOMY AS CAPACITY

The account based on respecting autonomous choiceswas unable to show that it would be wrong to treatpatients or involve participants in research without theirinformed consent because it told us what we had to do ifsomeone had made an autonomous choice, but not thatit would be wrong to act unless they had done so. It couldonly have done that if everyone who has not giveninformed consent had made an autonomous decision torefuse – which as we have seen is not the case. Other12 Beauchamp and Childress, op. cit. note 9, p. 104.

Respecting Autonomy without Disclosing Information 3


accounts of what it is to respect autonomy that areprominent in the medical ethics literature are verydifferent in this respect.

Gerald Dworkin, for example, has argued thatinformed consent is needed to respect autonomy where hetakes ‘autonomy’ to refer to a capacity that most peoplehave, rather than to a characteristic of a decision thatthey make.13 The details of Dworkin’s account have beencriticized,14 but other accounts of autonomy as a capacityhave been proposed. Raanan Gillon, for example, takesautonomy to be, ‘the ability and tendency to think foroneself, to make decisions for oneself about the way onewishes to lead one’s life based on that thinking, and thento enact those decisions . . .’;15 Neil Levy adopts anaccount of autonomy as the capacity to control one’sbehaviour over time in his account of the way addictionundermines autonomy;16 and Eric Cave adopts anaccount of autonomy as the capacity to control our ownmental life, and to manage our concerns, in arguing thatwhat is wrong with manipulation is that it fails to respectthis capacity.17

If ‘autonomy’ refers to the capacity to make one’sown decisions and to manage one’s own concerns, thenrespecting that capacity requires us to allow people tomake their own decisions and manage their concerns inthe way they choose.18 Denying a competent person theopportunity to decide whether or not to have a certaintreatment, or to take part in a particular research project,would be to fail to respect their autonomy in this sense.The reason for this is that, as Scanlon puts it in a differentcontext,

In a situation in which people are normally expected tomake choices of a certain sort for themselves . . . nothaving or not exercising this opportunity would beseen as reflecting a judgment (their own or someoneelse’s) that they are not competent or do not have thestanding normally accorded an adult member of thesociety.19

Behaviour that reflects this judgment would not respectthe person’s capacity for autonomy. It would be to treatthem as if they did not have that capacity, and treatingsomeone as lacking the capacity for autonomy is notconsistent with respecting the fact that they have it. Forthis reason treating a competent patient, or involving acompetent person in one’s research, without their consentwould involve a failure to respect their capacity forautonomy.

However, even if it is necessary to obtain patients’ orresearch participants’ consent in order to respect theircapacity for autonomy, it does not follow that there isa requirement to obtain their informed consent. For apatient to give consent to a particular treatment, or aresearch participant to give consent for a researchprocedure, they need to know at least roughly what isproposed. I cannot, for example, consent to my doctorremoving my appendix unless I have some idea that whatshe is going to do is to remove my appendix. Because ofthis, in order to respect autonomy in the sense we areconsidering here the doctor or researcher will need todisclose information about what they are going to do.This kind of consideration, though, will not generate arequirement that they disclose the range of information –such as information about the risks involved – that isneeded for informed consent. This is because, whilst Icannot agree to your doing something if I have no idea ofwhat you are planning to do, I can agree to your doingit without knowing about all the risks involved – thoughI might be ill advised to do so.

Despite this there would appear to be clear cases inwhich withholding information would be a failure torespect a person’s capacity for autonomy. Withholdinginformation can be done as a way of manipulating peopleand manipulation would be a failure to respect thiscapacity.20 The capacity for autonomy is the capacity tomake up one’s mind and to subject one’s choices, desires,and preferences to scrutiny and either to endorse orchange them. When someone attempts to manipulateanother person, what they are trying to do is to interferewith the exercise of this capacity. This attempt to usurpcontrol is, it seems, a failure to respect the person’sautonomy.

However, whilst it is possible to withhold informationin an attempt to manipulate patients or potential researchparticipants, as Taylor has argued not all cases of failingto disclose information are attempts to manipulate.21 Adoctor might, for example, not provide information justbecause she does not get round to it, or because she never(and her colleagues never) provide that type of informa-tion in this type of case. In neither case is her failure toprovide the information a case of manipulation. She is

13 Dworkin, op. cit. note 7, pp. 100–120.14 L. Haworth. Dworkin on Autonomy. Ethics 1991; 102: 129–139.15 R. Gillon. Ethics Needs Principles – Four Can Encompass the Rest –and Respect for Autonomy Should be ‘First Among Equals’. J MedEthics 2003; 29: 307–312: 310.16 N. Levy. Autonomy and Addiction. Can J Philos 2006; 36: 427–448.17 E.M. Cave. What’s Wrong with Motive Manipulation. EthicalTheory Moral Pract 2007; 10: 129–144: 138.18 This capacity comes in degrees. Accounts that centre on respect forthe capacity for autonomy generally take it that if a person’s capacityfor autonomy is above some threshold, we treat that person as autono-mous, whilst if it is below that threshold we do not. In this section Ifocus on those who are above this threshold (whatever it may be), as onthese accounts it is only those people who count as having the capacityfor autonomy.19 T.M. Scanlon. 1998. What We Owe to Each Other. London: TheBelknap Press: 253.

20 Cave, op. cit. note 17.21 Taylor, op. cit. note 6.

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not in these cases trying to control the patient’s decision-making process or to interfere with the independence ofthe processes that lead to their decision. As such, theseare not instances where her failure to provide informationconstitutes a failure to respect her patient’s autonomy. Asnot providing information in these cases does not consti-tute a failure to respect the patient’s autonomy, it cannotbe the case that one must disclose that information inorder to respect their autonomy.

What all this suggests is that, while it is important notto treat people without their consent if we are to respecttheir autonomy, the information disclosure requirementshere are limited. Whilst one ought not to withhold infor-mation as part of an attempt to manipulate patients orresearch participants, there would appear to be no posi-tive obligation on the basis of the requirement to respecttheir autonomy to disclose any information (other thanabout what one is going to do) to them. If this informa-tion is not disclosed then the patient or research partici-pant cannot give their informed consent. Hence it wouldappear that one could treat patients, or include partici-pants in one’s research, in a way that respects their capac-ity for autonomy even where one does not have theirinformed consent.

This may look problematic because where treatment orresearch involves a risk to someone’s health, respecting aperson’s capacity for autonomy seems to require allowinghim to decide for himself whether the benefits (to him) areenough to justify the risks (to him) of what is being pro-posed. But if someone is to make this decision for himself,then he needs to have the information necessary to makeit. As such, in order to respect a person’s capacity forautonomy it would seem that doctors and researchersought to inform him of the risks and benefits involved intreatment or research respectively so that he can decidefor himself if the benefits are worth the risks (rather thanthe doctor or researcher deciding this on his behalf).

There is something right about this, but it is too strongas it stands. Were a doctor to ask her patient if he wantsinformation about the risks of treatment, then she wouldbe treating him as someone who has the capacity todecide for himself what is valuable. If the patient saysthat he does, then respect for his autonomy would appearto require that his doctor provide it. But if the patientsays he does not, or that he only wants to know aboutcertain types of risk, then respect for his autonomy wouldnot require his doctor to divulge more. Indeed, it mightwell be that to insist that he has more information andthat he uses it would be to fail to respect his capacity forautonomy. In that case the doctor would be deciding onher patient’s behalf what information he should use andin doing so she would not be treating him as someonewho can make up his own mind about what is important.That is, she would be imposing her own views about whatis relevant and how decisions should be made onto her

patient, and this is not an attitude of respect for hiscapacity to make decisions for himself. We might guide ayoung child through what is needed to make a gooddecision, but to treat a competent adult in the same waywould be to fail to recognize that he can do this forhimself. That is, just as deciding on a patient’s behalfwhat treatment he will have would be to treat him aslacking the capacity for autonomy; so deciding on hisbehalf what information he needs (whether that be todecide that he does not need any information or that heneeds full information) in order to choose whether or notto have that treatment would also be to fail to respect hisautonomy.22 For this reason the requirement to respectautonomy as capacity does not generate a requirement toprovide information except where this is something thatthe patient or research participant wants. Where they donot want it, there is no autonomy based reason to provideit. In such cases the person cannot give informed consent,but it would not be a failure to respect his autonomy togive him treatment or involve him as a participant inone’s research.

What all this suggests is that if there is an obligation torespect the capacity for autonomy, then treating a patientor including someone as a research participant withouttheir consent would be wrong because it would fail torespect that capacity. Whilst as we have seen there is alsoa requirement not to manipulate patients or research par-ticipants, this does not generate a requirement to discloseinformation merely that one not withhold it as a meansto manipulate them. What is needed in order to respectthe capacity for autonomy is to give patients and researchparticipants the opportunity to have information if theywant it, and not to treat them or involve them in one’sresearch without their consent (whatever informationthey may have wanted to have). As such, informedconsent is not needed in order to respect the capacity forautonomy even if consent is needed for this purpose.

3. AUTONOMY AS SOVEREIGNTY

The idea of autonomy was initially applied not to peoplebut to city-states – an autonomous city was one that ruleditself, in contrast with a colony that was ruled by anothercity.23 The third sense of ‘autonomy’ as it occurs in bio-ethics ties it much more closely to this political sense thanthe two we have looked at so far. The idea can be cashed

22 For this reason it would seem that the requirement to respect aperson’s capacity for autonomy means that we should only act topromote their autonomy (by providing more information) if the personrequests such help.23 T. May. 2005. The Concept of Autonomy in Bioethics: An Unwar-ranted Fall From Grace. In Personal Autonomy: New Essays onPersonal Autonomy and Its Role in Contemporary Moral Philosophy. J.S.Taylor, ed. Cambridge: Cambridge University Press: 299–309: 306.



out in various terms: Joel Feinberg refers to it as ‘thesovereign authority to govern oneself ’;24 James Wilsonrefers to it as ‘a sphere of decisional privacy’;25 and DavidArchard calls it ‘a jurisdictional domain over which aperson exercises his will’.26 Whilst there are differencesbetween these accounts they all point to the same basicidea – there is a domain over which the individual hasauthority and is sovereign. Within that domain the indi-vidual rules him or herself, and hence this is the sphere oftheir autonomy. There are various possible bases thatcould be, and have been, used to argue that individualshave such a domain. These include accounts based onsome form of social contract,27 accounts based on own-ership (either self-ownership or ownership of one’sbody),28 and accounts based on the value of liberalism.29

The core idea of autonomy as sovereignty is that thereis an area over which I have authority, or a domain overwhich I am sovereign. If this is the case, then an act thatencroaches on or invades the area over which I am sov-ereign without my consent would be wrong for the samereason that it would be prima facie wrong to interfere inthe internal affairs of a sovereign state – unless one hasthe agreement of the relevant authority, to do so is tousurp or ignore the rightful power. As Archard puts it,‘to be sovereign over one’s self is just to be entitled not tohave things done to one without permission.’30 As such,if one is sovereign over a particular domain or type ofdecision, then for someone else to act in a way thatintrudes into that area would be to fail to respect one’sautonomy. On this type of account we can see whyconsent may be needed for treatment. There are somethings where it is up to me whether or not they canpermissibly be done (I and I alone have the authority toauthorize them). If inserting things into my body is one ofthose things then to treat me in this way without myconsent would be to fail to respect this fact about me.

Even if accounts of this type generate a requirement toobtain consent, it is not clear that they generate require-ments to obtain informed consent. As with autonomy asa capacity, some information will need to be disclosed ifconsent it to be obtained. As Manson and O’Neill pointout in a different context, ‘Consenting fails unless respon-dents grasp what was being requested, and that it was arequest (not, e.g., an order or a threat) . . .’.31 The basic

idea here is that consent permits or authorizes a doctor orresearcher to do something that would otherwise bewrong, but if the patient or research participant signi-ficantly misunderstands what is going to be done the‘consent’ she gives will not authorize or permit thataction – it does not effectively operate to permit them todo what they in fact propose. Similarly, if the patient doesnot understand that they are able to refuse, it is notthe case that they have granted permission voluntarily.In that case, although they say they agree, this may bebecause they think they have no choice, and it wouldbe unsafe to treat this as permission to do what wouldotherwise be wrong.

This minimal account of what patients or research par-ticipants need to understand for their consent to effec-tively permit treatment or research seems right for thesereasons. But, again, as with the account of autonomy asa capacity, it does not appear that this type of reason canbe extended to generate a requirement that the levelsof information needed for informed consent must bedisclosed if one is to respect autonomy as sovereignty.The requirement to respect autonomy in this sense is arequirement not to usurp the rightful decision makingauthority, in this case the patient or research participant,by making a decision on their behalf. This requires thatone let them make the decision, and that one respects thedecision that has been made. But the requirement to deferto the rightful authority and obtain their decision beforeacting does not in itself require that one provide themwith information about things like the consequences ofwhat is to be done. Patients or research participants canmake decisions to allow treatment or research withouthaving this information. If they have made that decision,then treating them or involving them in one’s researchproject would not be to fail to respect their autonomy assovereignty because it would not be acting without thepermission of the relevant authority.

This is not to deny that there will be cases in whichwithholding information would undermine the voluntari-ness of the consent given – by for example deceiving ormanipulating the patient or research participant.32 But, aswe saw earlier, it does not follow from this that all casesin which information is not provided are problematicin this way. To see this consider a case where a patientagrees to treatment before he has received informationabout the risks involved. In this case the patient has notbeen deceived, nor has he been manipulated, into decid-ing to have the treatment. There seems little reason tothink, therefore, that his agreement is not voluntaryenough to constitute consent to treatment. Further-more, if the doctor does not then disclose informationabout risks and harms, this is also not a case of manipu-lation. The doctor has the patient’s consent and so has

24 J. Feinberg. 1986. Harm to Self: The Moral Limits of the CriminalLaw. Oxford: Oxford University Press: 28.25 Wilson, op. cit. note 8, p. 353.26 D. Archard. Informed Consent: Autonomy and Self-Ownership.J Appl Philos 2008; 25: 19–34: 31.27 Wilson, op. cit. note 8.28 For discussion see Archard, op. cit. note 26.29 A. Ripstein. Beyond the Harm Principle. Philos Public Aff 2006; 34:215–245.30 Archard, op. cit. note 26, p. 30.31 Manson and O’Neill, op. cit. note 6, p. 93. 32 Feinberg, op. cit. note 24, p. 278.

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permission to treat, failing to provide further informationcannot undermine the voluntariness of that previouslygiven agreement.

What can we conclude from all this? If patients’ orresearch participants’ consent is to count as consent (andso ensure that treating or carrying out research is notwrong because it fails to respect the patient’s autonomy)then they must know at least in general terms what isgoing to be done. Hence this information needs to bedisclosed to them. It is also important that the doctor orresearcher not manipulate her patients or research par-ticipants into giving that agreement, or obtain it bydeception. This creates a requirement that she not with-hold information for these purposes. If she did, the vol-untariness of the consent obtained would be underminedand for this reason it could not safely be regarded asgranting permission to do what would otherwise bemorally wrong. But, this requirement to obtain voluntaryconsent, as we have seen, does not mean that there isa general requirement to disclose anything more thanminimal information. As such, treating patients orinvolving participants in research who have not receivedinformation, and hence have not given informed consent,would not be a failure to respect their autonomy (where‘autonomy’ relates to sovereignty), although treatingwithout consent might be such a failure.

CONCLUSION

We have now considered in some detail the threeaccounts of ‘autonomy’ that have been used to supportthe idea that respect for autonomy requires informedconsent. We have seen that on at least two of these,autonomy as capacity and autonomy as sovereignty,consent may be needed for treatment or carrying out

research on competent individuals. This is becauseif doctors or researchers were to proceed without thatconsent they would fail to respect their patients’or research participants’ autonomy. However, on noaccount did it turn out to be necessary that patientsor research participants understand more than what (ingeneral terms) was to be done by the doctor or researcher.Instead the level of information that needs to be disclosedin order to respect autonomy is broadly in line with thatpreviously required by English law to avoid the tort ofbattery. This is that the patient not be manipulated intoagreeing (which could be done by withholding informa-tion) and that she know what the doctor is going to do.As such, informed consent in any rich sense of ‘informed’(which would include knowledge about things like therisks and benefits involved) is not needed in order torespect autonomy. The idea that informed consent isneeded in medicine and research, however, has most com-monly been based on the idea that it is needed in order torespect the patient’s or research participant’s autonomy.This standard reason for thinking that informed consentis needed is therefore mistaken. It does not follow fromthis that there is no need to obtain informed consent. Butif there is such a requirement, the reasons for it must lieelsewhere than a concern to respect autonomy.

Acknowledgements

I would like to thank John Coggan, Angus Dawson and AnthonyWrigley, and audiences at Keele and Bristol Universities, for helpfulcomments on an earlier version of this paper.

Tom Walker is a lecturer in the Centre for Professional Ethics atKeele University. His main research interests are in public health ethics,in particular the ethical issues raised by addiction and alcohol consump-tion, distributive justice and the allocation of scarce resources, andquestions around autonomy.



respecting autonomy without disclosing information

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