• Autonomy

While we might associate ‘the unconscious’ with repression and the psychodynamic theories of Freud,1 it has a more general sense and application that mean it is an important concept for contemporary ethics. Paying attention to the significance of associations, beliefs, presumptions and emotions that we have, but are not consciously attending to, is important for a more nuanced understanding of autonomy. Unconscious bias is an important issue for health education and clinical ethics, while beliefs and desires that are not yet fully formed can be very important issues in therapy with younger people. The Journal of Medical Ethics has published a number of papers over recent years that discuss the ways we frame clinical interactions and make decisions in the light of the unconscious.

The recognition that we all have implicit, or unconscious biases should be acknowledged in health education and learning opportunities for addressing it created. Unconscious bias can be covered in the curriculum via cultural competence frameworks because these provide tools for students to view each patient as a unique individual and not make assumptions about them based on stereotypes.2 While this is a promising way to encourage students to reflect on what they might assume and bring to a clinical interaction, the medical curriculum itself can unreflectively make assumptions that reinforce stereotypes and inequities. Lokugamage et al have argued that the medical curriculum needs to be ‘decolonised’ so that concepts such as ‘healing’ are not presented from only within a western frame.3 In addition to ethnicity, gender is another concept where unconscious bias needs to be remedied within health education and professional practice. In a previous issue of the JME Hutchison distinguishes four ways in which gender biases impact women surgeons.4

Therapeutic misconception is an important and well documented phenomenon where research participants persist in viewing research as therapeutic, despite having given an apparently ‘informed’ consent. Explaining this phenomenon is a task for ethics and Charuvastra and Marder5 have suggested that we need to look beyond cognitivist accounts of belief and attend to ‘unconscious emotional reasoning’ which they think underpins the therapeutic misconception. Just as a patient or research participant might act on considerations that are not straightforwardly cognitive and articulated, doctors too can unconsciously succumb to conflicts of interest. Drawing upon an observation in the Talmud, Gold and Appelbaum6 argue that gifts have the potential for subconsciously influencing the actions of doctors and we should be wary of their potential fto create conflicts of interest.

The analysis of unconscious beliefs and emotions in ethics is unified by the way it draws our awareness to the limitations of what we might, at first blush, take to be important or think we should do. It therefore prompts us to think more carefully and reflectively about what autonomy is and how it can be supported, nurtured and thereby respected. This is particularly so when interacting with adolescents where it is critically important that they are encouraged to make their own decisions but where that should also be tempered by an awareness that their individuality is still a work in progress. When young people experience gender dysphoria, complex issues around self-understanding and identity are brought into sharp relief and such issues are skilfully analysed by Lemma and Savulescu in this issue of the JME.7 Central to mitigating the influence of unconscious biases is finding ways to bring them within the scope of our self-understanding. In the case of gender dysphoria, Lemma and Savulescu say that is about ‘… reducing the absence of controlling influences through broadening the scope of our awareness of the unconscious determinants of our decisions. By ‘controlling influences’ we have in mind, for example, the impact of external family and/or cultural pressures that are implicitly operating on our minds.’ (p4) They extend this scope to a young person’s embodied experiences and how the environment they are in influences their self conception. They proceed to observe that ‘…understanding the breadth of meaning and function that is subsumed under ‘transgender’ as an identity referent is helped if we think not only in terms of societal ‘gender’ ascriptions but also in terms of the subjective experience of embodiment, of the body’s unconscious identifications and hence the psychic function of the modification of the body’. When viewed in this way, nurturing and respecting autonomy becomes much richer and involves time, space for reflection and thoughtful discussion. There is therefore much more to ‘respect for autonomy’ than a checklist approach to informed consent might be taken to imply.