The American philosopher Martha Nussbaum has written a wonderful book with great relevance for psychiatric care, general care and school settings. It’s called Frontiers of Justice. In the book she says that all pedagogy and care is about removing autonomy. We do this when we decide that the person we work with should brush their teeth, get up in the morning, take out a book in school and all other demand situations. The paradox is that the goal of education and care for people with disabilities is to increase their autonomy. Nussbaum believes that there is an ethical problem, but that it can be solved by a good and well thought-out ethical approach. She believes that it may be ok to remove autonomy if we have a good argument.
There can be various arguments. Those I think are ok in my work are:
- Avoidance of danger. We take away autonomy regarding playing on the motorway, and sometimes we even grab hold of a person who is on their way out onto the main road to prevent the person from being injured.
- We decide that the person we work with should brush their teeth and take a shower. We may not be as robust as when avoiding danger, so our approach to get the person to say yes to the need to brush your teeth or showering should be good.
- The actual autonomy increases. People with developmental disabilities or psychiatric problems are rarely particularly good at deciding for themselves. They often act on impulse or stereotypically, that is, in the same way every time, without it being an active choice of actions. By limiting the autonomy in certain situations, we can increase their actual autonomy.
This last argument is central to this text. Actual autonomy can in fact be increased by it being limited.
We can illustrate this with the autonomic traffic regulations metaphor.
Government has limited my autonomy by law. I cannot drive on the left side of the road, only on the right. I think this is a huge limitation of my freedom to decide my life. But it increases my actual autonomy.
I drive many miles in my work, between different cities where I lecture or tutor. The evening that I’m writing this text is on a Wednesday, when I already this week have driven 1300 miles. I started the week in Sweden in Stockholm, then Gothenburg, and then on to Karlstad. Today I’m in Esbjerg in Denmark and before the week is over, I will be back in Sweden and have been to Varberg as well. It works only because the government has limited my autonomy. If everyone could decide for themselves if they wanted to drive on the right or left side of the road, it would be extremely dangerous to drive faster than perhaps 10 mph. It would mean that I couldn’t choose to work as I do. So by limiting my autonomy regarding which side of the road I get to drive on, my autonomy regarding where I want to go has increased. So my actual autonomy has increased, because where I can go is more important than on which side of the road.
When we make a schedule for a person with autism it is a way to limit the autonomy to increase the actual autonomy. Because people with autism who need a schedule usually have difficulties making good choices. If they can do whatever they want, there is a risk that they will always choose the same thing, or they act on impulse and choose without thinking it through. But to give them a schedule is an ethical challenge. In order to have a good argument, we must be sure that there is genuine autonomy. This can be done by having a free activity with a schedule (an activity where you get to choose from a number of alternatives). If the structure is good, the person will choose flexibly between the various activities from the schedule. If the framework is too loose, the person most likely will choose stereotypically, for example by always selecting the same activity or by always choosing the activity presented first.
Therefore the schedule must consist of various activities that are equally attractive. Also I would choose stereotypically if I always were to choose between going for a jog or having a coffee. If the activities in the schedule are equally attractive the person will choose flexibly if he/she is unstressed. This means that we increase the structure if the person can’t choose, and gradually loosen or keep the framework we have if the person is able to. Just like I drive to different places because I can when the traffic rules are made up in a way that makes me actually dare drive at a reasonable speed.