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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 conicting value commitments within pluralist societies. But they also arise from substantive philosophical disagreements about the conditions and capacities necessary for autonomy, and the specic 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 rst 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 rst-person perspective.3 There are different ways in which this intuition can be spelt out, for example, as identication with ones will, reective 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 reectively endorses the value commitments that dene 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 difcult 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 rst personal and thoroughly relational. On the view I develop, for an agent to have normative authority over her decisions and actions it is not sufcient 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 articial 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 rst 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 nal assessment, the assessing psychiatrist amended her nding 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 rst 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 afrming this nding, 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 articial 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 nd such a life intolerable. Ms. B. was clearly sufciently 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 benecence 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 conict 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 insufcient 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 rst-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 rst-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 rst-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 difcult 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 rst-person experience may be internally conicted, 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 signicant 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 difcult business of saying goodbye to friends and family. Although the hospital trust therefore may not have been justied in their assessment of Ms. B.s competence, the problem of internal conict and ambivalence suggests that the rst-personal subjective character of experience is an insufcient basis on which to ground normative authority and respect for autonomy.13 Reective endorsement theories are motivated by the same underlying intuition about the centrality of the agents rst-person perspective, but such theories require more stringent conditions for autonomy, namely that the agent reectively 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 conict, through processes of reective 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 conict, and integrate the various aspects of our identity into a unied 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 reective endorsement view of normative authority. In reecting 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 difcult 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 difcult 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 reect 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 condent 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 nds 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 ourish. 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 difculties 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 rst 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 Briey, 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 reection to count as adequate. The rst are competency conditions that specify the competences and capacities necessary for autonomous reection, 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, dening and reecting on her values and commitments free of social inuence. 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 reection 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, identication 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 difculty, Christman stipulates two important further constraints on procedural accounts. The rst 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 species that a person is autonomous with respect to a belief, desire, value commitment or decision only if, were she to reect on the historical process of its formation, she would not repudiate or feel alienated from it. The nonalienation constraint differs from endorsement and identication views because it does not require wholehearted identication, 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 reected 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 reection not be subject to various distorting inuences (psychological, social, or physical) that interfere with self-

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awareness. These might include overpowering emotions, being under the inuence 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 reect.21 I am not condent that the non-alienation constraint would be sufcient to show why Mrs. H.s request to discontinue treatment is non-autonomous. For even if she were to reect 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 reection has been subject to various illegitimate distorting inuences. These might include distorting inuences on her current statefor example, depressionas well as distorting inuences in her past historyfor example, not having sufcient educational or other opportunities to develop the capacity for critical reection, 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 sufcient 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 satises Christmans more stringent procedural constraints but reectively 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 reection, and that it is made under conditions that do not curtail her capacities for autonomous reection. 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 rst-person perspective. To the extent that substantive relational theories such as Oshanas dene 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 rst concern regarding perfectionism, the normative authority of the rst-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 justiably 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 signicantly 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 insufcient for grappling with the difcult 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 dening 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 rst 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 reection 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 difcult 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-condence 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 reexive 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 conicts arising from the obligations of different social roles, and so on. Lack of self-trust or basic self-condence impairs our capacity to understand ourselves and to respond exibly 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 difcult 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 nd their lives robbed of meaning. But it does require understanding why, given her reective 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 reexive 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-condence 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 exible person would experience difculty 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 afrm 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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authority is thoroughly relational while also upholding the intuition that normative authority is grounded in an agents rst-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 nancial 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 sufcient 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 conicts 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 specied, for example, by Christman are satised. 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 nd 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 signicant 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 ourishing, 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 nd 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 nd reasons for living and to envisage a possible future in which she would nd her life meaningful. In other words, it involves both respecting Mrs. H.s rst-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 difcult 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 ourishing.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 ourishing 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 conicts 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 ourishing 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 justied (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, ourishing 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 Regured, 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 identication theories, see especially Harry Frankfurt, Freedom of the Will and the Concept of a Person and Identication and Wholeheartedness, in Harry Frankfurt, The Importance of What We Care About (Cambridge: Cambridge University Press, 1988); and Gerald Dworkin,

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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 Regured, 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/judgmentsles/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 rst-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/judgmentsles/j1075/B_v_NHS.htm, 12. 13 Internal conict and ambivalence may not always compromise autonomy. For an agent may selfreectively 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/judgmentsles/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 difcult situations. 18 For further discussion see Mackenzie and Stoljar, Autonomy Regured. 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 rst 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 justied. 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-reective 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.