Photography by Dr.Friedrich Stiefel / Gruyére, Swizerland

Chapter 3. Human dignity and Autonomy

–The fallacy of Autonomy, Self-determination, and the Right to Self-determination –

1. An Overview of "Autonomy, Self-Determination, and the Right to Self-Determination"
In Chapter 1 and 2 of this essay, I wrote that key-pont in Kant’s (Immanuel Kant, 1724~1084) concept of "human dignity" is autonomy, which means unconditional respect for individual freedom and its regulation, and the idea that one's duty to oneself is immediately linked to one's duty to others1)2).
Kant's definition of autonomy can be summarized as consisting of the following three phases: 1) The right to make one's own decisions without interference from others, 2) The ability to make considered decisions through the independence of one's mind, and 3) The freedom to live an ideal and independent life. He also argued that these are moral rights that guarantee human dignity.3)
The word “Autonomy” is derived from the ancient Greek auto (self) and nomos (law). The original meaning comes from the Latin sister word autonomos (to live by one's own laws). In English, it expresses the idea of "one who gives oneself one's own law."
Autonomy is widely regarded as a fundamental principle of human existence and as an essential principle of modern Western society, but it is also a term that meets with a degree of skepticism. Autonomy and self-determination are, in fact, often used synonymously. Kant's concepts of autonomy and self-determination, having come down to us through the works of Friedrick W. Nietzsche（1844~1900), John B. Rawls (1921~2002), Jurgen Habermas（1929~) and others, are still widely debated today across a wide of fields such as politics, sociology, law, medicine, philosophy, psychology, and religion.
The term “self-determination” was central to the advocation for the right of people to self-determination during the period of decolonization that followed World War II. The United Nations Charter at that time defined “self-determination” as possessing two meanings: one being the right of a nation to choose its political, economic, social, and cultural systems without hindrance, and the other being the right of a people to constitute themselves as a nation or freely determine their relationship with existing states. Even today, the words self-determination and autonomy are used in movements advocating for expanded autonomy in European regions such as Catalonia in Spain, each region in Italy, and Scotland in the United Kingdom4).
The words autonomy and self-determination can be said to be metaphors for the assertion of the rights of people whose existence and decisions have not been recognized in society.
In the field of medicine and healthcare, the concepts of autonomy and self-determination have evolved, within the concept of the Quality of Life in the latter half of the 20th century, into terms that are frequently relied upon to resist physician-led paternalism. Through numerous declarations and interdisciplinary studies during this period, autonomy has become a primary ethical principle in various domains such as medical ethics, bioethics, and research ethics. The principle of respect for a patient's personal autonomy in Principles of Biomedical Ethics (1979) by Tom L. Beauchamp and James F. Childress5), and the Patient Self-Determination Act enacted in the United States in 19916), are two notable examples.

2. The Fallacy of “Those Concepts” 7)
While the Japanese translation of “autonomy” commonly uses the term jiritsu (autonomy), considering its context in the field of Japanese medicine and healthcare, the Kantian concept of jishu (independence, definition1) appears to be more appropriate3)5). Moreover, there is a significant difference between the terms “self-determination” and “right of self-determination”. “Self-determination” refers to the ongoing individual judgments, choices, and actions that a human makes in the face of life. On the other hand, “right of self-determination” denotes the recognition by society or the state of the self-determined actions as an individual's right. The process of self-determination involves recognizing one's own stage of development and takes place within the context of interactions with others. Essentially, there is no pure self-determination. On the other hand, the right of self-determination is an abstract norm assumed to be universal, in which individuals are entrusted with its application, leading to the risk of the diverse values and relationships within society being disregarded.
In a sense, the pluralism of the Western perspectives on human dignity and autonomy can be considered a fallacy. This is evident in the field of bioethics. In the United States, there is a tendency to disregard human dignity and prioritize the principle of autonomy, which sets it apart from the European approach. Although European countries have been welcoming with regard to human dignity, there yet persists some inconsistency in its recognition. Germanic countries, such as Germany and Austria, believe that dignity is a universal value inherent in all human existence (even embryos and fetuses), and they also seek to extend this to animals. Belgium is said to be a microcosm of Europe as a "country that insists on the diversity of bioethics and its multicultural horizons." Belgium has a long history of debate and has tended to emphasize autonomy over dignity. The argument is that the fundamental value of bioethics is, first of all, individual freedom. Deductively, they posit that the “dignity of human existence'' is the true value, and it is up to each individual to determine what constitutes their dignity; in other words, their autonomy. Prof. Luc Deliens of Belgium, who gave a lecture on the issue of euthanasia at the 1st Sapporo Conference for Palliative and Supporive Care in Cancer (SCPSC) in 2014, is scheduled to give a lecture on end-of-life issues at the 5th SCPSC in 2026. In contrast, France positions human dignity at the center of bioethics and biolaw, demanding alignment with autonomy in a Kantian sense. The United Kingdom follows an American-style approach to bioethics, emphasizing autonomy, without directly referencing the concept of human dignity in legal thinking. While the majority of countries interpret human dignity as an intrinsic value, there is a minority that views it through the lens of autonomy. The difference between these two positions is a constant source of debate, particularly in the context of the issues surrounding euthanasia

3. The Future of “Those Concepts”
The concept of “human dignity,” which encompasses “those concepts”, has the potential to be a blessing to the current changes occurring in the world10). This means entrusting the future of humanity to the concept mentioned at the beginning of this essay: “Unconditional respect for individual freedom and its regulation, and that one's obligation to oneself immediately becomes an obligation to others.''
References
1）2023.1.19 A New Year's Message from the President 2）2023.6.1 Message on “Human Dignity" from the President, Dr. Ishitani 3) Oliver Sensen (ed). Kant on Moral Autonomy. Cambridge University Press. 2022
4）Peter Hilpold (ed). Autonomy and Self-determination; Between Legal Assertions and Utopian Aspirations. University of Innsbruck, Austria. 2018
5）Tom L. Beauchamp & Jammes F. Childress (ed). Principles of Biomedical Ethics (8th ed) Oxford University Press, New York. 2019
6）Patient Self Determination Act, Dac Teol, Sasan Ghassemzadeh (ed) . StatePearls. Aug. 28.2023
PMID: 30855881 Bookshelf ID: NBK538297 7) Fallacy.  誤謬；https://ja.wikipedia.org/wiki/誤謬
8) Kato, Yasushi, Goto Reiko (ed). Dignity and Survival. Hosei University Publication Society, 2022
9）Vasil Gluchman. Nature of dignity and human dignity. J. Human Affairs.　Vol.27, Issue 2.  https://doi.org/10.1515/humaff-2017-0012

　Kunihiko Ishitani
President of The International
Research Society of the SCPSC
President, Higashi Sapporo Hospital
Asian Editor, BMJ Supportive & Palliative Care

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