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 of
the 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 commitments within pluralist societies. But they also arise from substantive philosophical 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 decision 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 are
necessary 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 relational approach to the principle of respect for 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 autonomy
competence 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 within
moral psychology concerning the basis of autonomous agents normative authority 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 different 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 identitymay
have 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 mistrust 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 she
does so autonomously.
The second problem arises from debates concerning what grounds the normative 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 conditioning when the agents practical identity does not seem to be fully her own. Such
cases 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 relational approaches to autonomy, which hold that autonomy is a socially constituted
capacity, are best able to address these problems. Recently, however, John Christman has expressed the concern that by deeming certain persons non-autonomous,
some relational approachesthose that stipulate substantive not merely procedural 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.

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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, relational 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 of
weak 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, Dame
Elisabeth 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-threeyear-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 quadriplegic, completely paralysed from the neck down and requiring artificial ventilation. 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 competent by each assessment. After the last assessment, preparations were made to
switch off the ventilator. However, the day after the final assessment, the assessing
psychiatrist 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 whole
period, 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 respect
to 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 exercise 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 selfdetermination with respect to ones life and ones bodily integrity trumps other
considerations, including the principle of beneficence or the medical teams judgments 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 responsibilities to save life rather than end it, these concerns should not override the
patients 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 as
subjects.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 obligation 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 is not achieved 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 tremendous
cost 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 important 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 humanity 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 internalized oppression. It is these kinds of cases that raise complicated ethical questions 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. apparently
expressed 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 indication that she was not competent and that her request for ventilation to be withdrawn 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 nevertheless
relieved 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 character 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 intuition about the centrality of the agents first-person perspective, but such theories require more stringent conditions for autonomy, namely that the agent
reflectively 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 normative 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 our
normative 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 unconditional 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 normative 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 disability 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 normative 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 case
are 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 in
answering 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 so
acceding 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 between
John 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 interrelated, claims. The first claim rejects the individualist assumptions about agency
implicit in mainstream conceptions of autonomy within bioethics, political philosophy, 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 a
number 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 conceptual sense. There are also differences concerning whether the conditions necessary 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 well
be 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 that
specify 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 suggests that, in addition to these standard conditions, the competence conditions for
autonomy should be expanded to include capacities that are central to interpersonal relations, such as capacities for care, empathy, intimacy, and social cooperation. The second, authenticity, conditions specify what is required for an
agents values and motivations to be considered truly her own. Individualist
conceptions 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 constituted 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 and
competence 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, identification 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 authenticity
conditions 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 nonalienation 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 a
person 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 conditions 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 influence of hallucinatory drugs or other substances, being subject to physical or
emotional intimidation or manipulation, being depressed or mentally ill, or being
deprived 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 autonomous because her capacity for reflection has been subject to various illegitimate
distorting influences. These might include distorting influences on her current
statefor 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 explanations 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 and
values 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 autonomous, 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, but
who 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 choosing otherwise, she endorses this choice as an authentic expression of her practical identity, thereby seeming to satisfy the conditions for autonomy on the
procedural view. Oshana argues that even if the Taliban woman exercises occurrent autonomy with respect to this particular choice, once she has made this
choice she has forfeited her global or dispositional autonomy.25 Her social situation, 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 that
while a relational theory such as Oshanas emphasizes the importance of recognizing the social embeddedness of agents, by insisting that some social relationships 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 relational 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 practical
identity 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 relational
theories 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 Christmans
objection 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 value
of 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 intervention. 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 perspective 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 perspective 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 and
paternalism. Even though citizens might have de jure rights to political autonomy,
that is, rights against the state to certain legal and political liberties, whether or not
they in fact possess or exercise high levels of personal autonomy, 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 to
which 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 to de jure political
autonomy, the threshold level of competence required ought to be minimal.
Agents who meet this minimal level of competence ought to be treated as politically 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 underdeveloped 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 question 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, Christman
provides 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 citizens de jure rights 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 reference 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 authority 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 vulnerable 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 autonomous reflection and deliberation requires having certain attitudes toward oneself,
in particular, attitudes of self-respect, self-trust, and self-esteem.33 I want to draw on
a version of this view proposed recently by Joel Anderson and Axel Honneth.34
Anderson and Honneth characterize the attitude of self-respect as 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-trust or basic self-confidence is
the 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. The
attitude of self-esteem or self-worth is a fundamentally evaluative stance toward
oneself; it involves thinking of ones life, ones commitments, and ones undertakings 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 her
decision 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 selfconception, it has normative authority for her. With respect to self-trust, although
Ms. B. obviously struggled with the decision to have treatment withdrawn because
it 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 had
anticipated; 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 misunderstanding, 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 as
able 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 if de 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 the
court 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 relationships and are particularly vulnerable to abusive intimate relationships and bodily
violations. Mrs. H.s capacities for self-trust may have been eroded by subordination within her marriage or they may not have been well developed to begin
with, 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 no
longer 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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527

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 must
have 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, selftrust, 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 reasongiving, in holding agents morally and legally responsible for their actions, in
interpersonal 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 authority
is a matter of degrees and domains. Someone may have a strong sense of normative 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, our
relationships with others in all the different spheres of our lives. And selfinterpretation is thoroughly relational and socialit is only in and through our
relationships and interactions with others that we acquire sufficient selfunderstanding 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 requirement that she is either self-transparent or has privileged epistemic access to her
motivations, 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 recognition 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 flourishing, 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 selfrespect, 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 respecting 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 may
enable 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 attitudes
toward 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 acknowledges. Moral perfectionism is the view that some goods, activities, and ways of
life, are not valuable and are not consistent with human well-being or flourishing.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 form
of 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 different 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 would
suggest 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. This
view is sometimes thought to involve support for coercive and extensive governmental interference with libertyindeed this concern about coercive interference 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, compelling 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 of
non-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 valuable 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 Anderson 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 recognition 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 approach
to 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 institutions 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 social
conditions 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 Philosophy 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 Mackenzie 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 Substance of Autonomy, in Personal 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, in Relational 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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531

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-Level
Self, 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 selfreflectively 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, in Relational 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 the
will. See Frankfurt, Rationality and the Unthinkable, in The 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, in The 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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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 clinical
decision making in difficult situations.
18
For further discussion see Mackenzie and Stoljar, Autonomy Refigured.
19
See especially Christman, Self-Transformation; Liberal Individualism; and Liberal Legitimacy. 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; and Personal 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 of Personal 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 me
beyond 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, Hypatia 8 (1993): 99120.
34
Joel Anderson and Axel Honneth, Autonomy, Vulnerability, Recognition, and Justice, in Challenges 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 not
always 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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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.