Enforced Medical Treatment & Refusal

A review of Freedom, Consent and Autonomy in Bioethics: Justifications for Enforced Medical Treatment and its Refusal, by Mirko Daniel Garasic.

The principle of autonomy is commonly given priority in contemporary bioethical debates. However, Mirko Garasic argues in his dissertation that autonomy is often used inconsistently and ineffectively in such debates. Rather than using this observation as grounds to reject the principle of autonomy, Garasic suggests a common sense approach to address the problem. First, he thinks that if we choose to employ the concept of autonomy in bioethical debate, we must be clear about what we mean when we use it. Second, Garasic thinks that in cases where we choose to place priority on the principle of autonomy, it is necessary to adequately justify why autonomy is morally salient. In the casuist tradition, Garasic makes his arguments by demonstrating the various ways that the principle of autonomy has been used (often with damaging effects) in real life cases of refused and enforced medical treatment.

In the first chapter the reader is given a historical overview of several interpretations of the concept of autonomy and some of the difficulties associated with defining it. Garasic takes this opportunity to highlight key distinctions between what autonomy has meant to philosophers like John Stuart Mill and Immanuel Kant. The views on autonomy of contemporary philosophers, such as Ronald Dworkin, Onora O’Neill, Tom Beauchamp and James Childress (among many others), are then compared and contrasted. But this chapter is not just a simple theoretical overview. Instead, Garasic introduces other issues that are central to his dissertation, such as mental illness and the biopolitics of power. At the end of the chapter, one of the basic questions that Garasic leaves with the reader is: when should a particular notion of autonomy be applied to a particular case in bioethics, and why?

Garasic’s second chapter fully immerses the reader in the ethical debate surrounding anorexia nervosa and the enforcement of medical treatment for this dreadful condition.  During his ethical analysis he carefully negotiates the difficulties surrounding the classification of mental illnesses and how such illnesses can become integrated into a human’s identity. As a result, the discussion raises important questions about how we should think about the autonomy and competency of those who suffer from mental illnesses such as anorexia nervosa.

The paradoxical case of Charles Laverne Singleton takes center stage in the third chapter. Garasic begins by explaining how Singleton was convicted of murder in the US state of Arkansas and was sentenced to death by lethal injection. The principle of autonomy soon becomes an integral part of the story when we learn that Singleton suffered from schizophrenia and required medication in order to become competent and eligible for execution. To complicate matters further, Singleton refused his medication and, as a result, the state authorities chose to enforce his medical treatment so that he would be well enough to be killed. Garasic uses this case to question the ends to which autonomy can be employed to justify actions in bioethics.  Following his discussion of the Singleton case, Garasic continues his foray into the intricate (and often puzzling) web of relationships between mental health, responsibility, punishment and morality of enforcing medical treatment.

Chapter 4 continues Garasic’s in-depth investigation into how the concept of autonomy is inconsistently used in bioethics. The chapter is brought to life with the use of two vividly explained case studies: 1) the Dax case; and 2) the Mbarka case.

The Dax case is about a man, named Dax, who was given lifesaving treatment after he suffered severe burns to his body caused by a propane explosion. The problem is that Dax never wanted his life to be saved and, at the time treatment was proposed, he was competent to make the decision to end his life.  Dax’s story is a distressing reminder of how medical paternalism can, in some cases, distort and obscure the value of autonomy in medical ethics.  For Garasic, this is a case of autonomy being marginalized when it matters most.

After discussing the Dax case, Garasic shifts his attention to the problem of hunger strikes and the Mbarka case. Sami Mbarka Ben Garci was a Tunisian prisoner in Italy who went on a hunger strike to protest being charged with rape. Unlike the case of Dax, when Mbarka needed an enforced medical intervention to stay alive during his hunger strike the necessary medical treatment was withheld and he died. The prison authority’s justification for withholding treatment was that it would respect Mbarka’s autonomy.

Garasic suggests that both the cases of Dax and of Mbarka are biopolitically unjust. Had autonomy been used consistently and correctly as a principle in both cases, he believes that Dax would have been allowed to die and Mbarka would have been kept alive using enforced medical treatment.

In Chapter 5 Garasic calls for us to revise and rethink the way the concept of autonomy is currently used in bioethics. Garasic’s conceptual analysis of autonomy is refreshing and honest. One particular passage of Garasic’s work does a great job summarizing some of his views:

Our autonomy, our freedom of choice, our entitlement to give or refuse consent for treatment is not as independent from the external world as commonly portrayed in contemporary Western society. This does not mean that we need to abandon the undeniable improvements that individual autonomy has produced in bioethics and political contexts. We only need to integrate them with principled autonomy. For the sake of stability, we have a duty to seek practical answers that can be understood by others (p.119).

I think Garasic makes very important points here. While our autonomy is important, we will always have some form of ethically binding relationships or dependencies on others. When we disregard these relationships we risk placing too much emphasis on autonomy and losing sight of other ethically significant values. According to Garasic, if we want to use the principle of autonomy to justify our actions we must use it effectively and in a way that is accountable to the rest of society.

Garasic’s research makes an important contribution to a growing literature in philosophy and biopolitics that challenges the traditional usage of autonomy as a bioethical principle. This work will be of interest to both analytic and continental philosophers working in applied ethics. The interdisciplinary nature of this dissertation means that it will also appeal to non-philosophers.

John Appleby
Centre for Family Research
University of Cambridge

Dissertation Information

Libera Università Internazionale degli Studi Sociali Guido Carli (LUISS). 2011. 139 pp. Primary Advisors: Sebastiano Meffettone and Daniele Santoro.


Image: Photograph purchased by Mirko Garasic.

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