Making autonomy an instrument: a pragmatist account of contextualized autonomy

Autonomy, a deeply valued attribute across diverse societies and cultures, is a central concept in ethics and philosophy. While widely considered important, its nature and function remain contested. This paper proposes a deeper understanding of autonomy rooted in pragmatist theory and contemporary psychological research. It adopts an instrumentalist strategy, viewing ethical concepts as instruments for moral problem-solving and a flourishing life. The paper introduces the concept of "contextualized autonomy," situating it within a review of individualistic and relational accounts of autonomy. This novel approach considers autonomy as an ability, not merely a property, and emphasizes its inherent contextual nature and transactional interaction with the environment. It will explore how this perspective allows for a synergetic enrichment of the concept through the integration of experiential and empirical knowledge.

The paper reviews two major trends in conceptualizing autonomy: individualistic accounts (e.g., Kantian) that view autonomy as an abstract capacity for self-governance and relational accounts that highlight the influence of social contexts and relationships. Individualistic accounts, while valuing autonomy as a source of human dignity, are criticized for neglecting the influence of social environments. Relational accounts, while acknowledging the impact of context, risk undermining the value of autonomy itself. The paper argues that both approaches offer valuable insights but lack a sufficient integration of empirical and experiential knowledge.

The paper employs a pragmatist and instrumentalist approach to analyzing autonomy. This methodology emphasizes the importance of clarifying concepts based on their real-world implications and usability. The authors propose a contextualized account of autonomy, conceptualizing it as a complex, composite ability encompassing several component-abilities: voluntariness, self-control, information, deliberation, authenticity, and enactment. The paper then uses a process of "synergetic enrichment"—a reciprocal interplay between theory and experience—to refine the understanding of these component-abilities. This involves drawing on evidence from diverse disciplines such as social work, disability studies, psychology, and neuroscience, particularly within healthcare contexts. The authors examine agent-related factors, context-related factors, and the interaction between the two for each component-ability, illustrating the contextual nature of autonomy and offering practical implications for healthcare and beyond.

The paper's key findings center on the contextualized and composite nature of autonomy. It argues that autonomy should not be viewed as an all-or-nothing concept but as a complex ability composed of interconnected components. **Self-Control:** The ability to delay gratification is identified as a crucial aspect of self-control, highlighting its impact on long-term outcomes. Agent-related factors (e.g., frontostriatal circuitry activity, mindfulness training) and context-related factors (e.g., social norms, social support, environmental distractions) significantly influence self-control. Strategies to improve self-control can involve both intrapsychic (e.g., attention training) and situational (e.g., creating supportive environments) approaches. **Information:** The importance of information in autonomous decision-making is discussed, extending beyond a simple focus on informed consent. Cognitive biases (e.g., framing effects, anchoring effects) are presented as influences on information processing, highlighting the complexities of informed decision-making. Context-related factors such as cognitive impairments, patient-physician relationships, and communication methods impact the ability to access, process, and utilize information. Shared decision-making models are highlighted as approaches to support autonomy in healthcare. **Authenticity:** Authenticity, or acting in accordance with one's values and preferences, is emphasized as a crucial component of autonomy. Agent-related factors (e.g., intrinsic motivation, developmental stage) and context-related factors (e.g., coercion, financial incentives, cultural norms) are examined. The influence of intrinsic versus extrinsic motivation and the concept of identified and integrated regulation are highlighted. The importance of concordance between decisions and values is discussed, particularly in healthcare contexts involving difficult choices.

The pragmatist account of contextualized autonomy addresses limitations of both individualistic and relational accounts by integrating empirical evidence and lived experience. The concept of autonomy as a composite ability, rather than a single, defining characteristic, allows for a more nuanced understanding of autonomous decision-making in varied contexts. The study’s findings underscore the significant impact of both agent-related and context-related factors on the exercise of autonomy and the importance of acknowledging and addressing these factors to support individuals’ ability to make autonomous choices and to improve their overall well-being. The concept of synergetic enrichment offers a valuable framework for integrating empirical research with ethical theory, enriching our understanding and application of the concept of autonomy.

This paper contributes a novel pragmatist account of contextualized autonomy, offering a more comprehensive and empirically informed approach. It emphasizes the composite, contextual, and transactional nature of autonomy as an ability. Future research should focus on developing multi-dimensional scales to measure autonomy as an ethical construct and assess the impact of interventions aimed at enhancing autonomy in various contexts.

The paper's focus on healthcare contexts limits the generalizability of some findings to other domains. The reliance on existing literature for the identification of component-abilities might not fully capture all relevant aspects of autonomy. Furthermore, the concept of synergetic enrichment, while conceptually valuable, requires further methodological development and validation.