Autonomy is NOT the right to do whatever you want

Homebirth advocates love the word “autonomy.”

They believe that the principle of autonomy gives them the “right” to have a homebirth, and the “right” to have the provider of their choice attend their homebirth. Many also believe that they have the “right” to insurance reimbursement for their homebirth.

As with so many things, autonomy is yet another concept that homebirth advocates don’t really understand. Most seems to think that the principle of autonomy means that an individual can do whatever she wants. That’s not what it means at all. The principle of autonomy means that people are free to choose between a range of options, but it does not mean that those options are unconstrained.

Consider the Wikipedia definition of autonomy:

… [I]t refers to the capacity of a rational individual to make an informed, un-coerced decision. In moral and political philosophy, autonomy is often used as the basis for determining moral responsibility for one’s actions. One of the best known philosophical theories of autonomy was developed by Kant. In medicine, respect for the autonomy of patients is an important goal as deontology, though it can conflict with a competing ethical principle, namely beneficence…

In the medical context:

… respect for a patient’s autonomy is considered a fundamental ethical principle. This belief is the central premise of the concept of informed consent and shared decision making… In the 1940s, the phrase “informed consent” appeared … Initially, discussions about informed consent focused almost exclusively on research subjects, but eventually has come to apply to the conventional physician-patient relationship as well. The seven elements of informed consent … include threshold elements (Competence and Voluntariness), information elements (Disclosure, Recommendation, and Understanding) and consent elements (Decision and Authorization).

Simply put, the concept of autonomy means that patients must be competent and give consent voluntarily. The must receive an explanation and recommendation, and they must demonstrate understanding of what they have been told. Only the patient can make the decision and authorize the treatment.

For example, when considering treatment for breast cancer, the patient must receive an explanation of treatment options and a recommendation. Only the patient can authorize the treatment, or she can refuse the treatment. The patient can choose between surgery, chemotherapy, radiation or a combination of those options. A patient can refuse any or all of these options. But notice what autonomy does NOT encompass.

Autonomy does NOT mean that her doctor is required to offer pseudoscientific or unapproved treatment.
Autonomy does NOT mean the doctor must provide her treatment at home.
Autonomy does NOT mean that the patient can choose her own provider to administer chemotherapy or perform surgery.
Autonomy does NOT mean that the government must offer a license to practice to anyone the patient feels is qualified.
Autonomy does NOT mean that insurance companies must pay for pseudoscientific or unapproved treatment.

In other words, the principle of autonomy means that a woman diagnosed with breast cancer has a right to accept or refuse the recommended options, and a right to a complete explanation of the risks and benefits of those options.

Moreover, while a patient has the right to choose a pseudoscientific or unapproved alternative “treatment,” and the right to administer it to herself, it does NOT mean that the medical profession, the government or anyone else must facilitate that right.

When it comes to homebirth, the principle of autonomy means that a woman has the right to refuse obstetrical interventions and the right to refuse to go to the hospital at all. Here’s what it does NOT encompass:

Autonomy does NOT mean that her doctor is required to offer pseudoscientific or unapproved treatment.
Autonomy does NOT mean the doctor must provide obstetrical care at home.
Autonomy does NOT mean that the patient can choose her personally designated “midwife” to attend her birth.
Autonomy does NOT mean that the government must offer a license to practice to anyone the patient feels is qualified to be a midwife.
Autonomy does NOT mean that insurance companies must pay for her homebirth.

The bottom line is that the principle of autonomy means that a woman does not have to go to the hospital to have a baby, but it means nothing beyond that.

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