The Perversion of Autonomy: The Proper Uses of Coercion and Constraints in a Liberal Society.

Five years ago it became clear to me that we were in big trouble. A psychiatrist friend who works at St. Elizabeth's Hospital told me about a young man who was a patient on his ward. The mm was known to be HIV-positive and, despite admonitions, was having sexual relations with several female patients, some of whom were not psychiatrically competent. The psychiatrist had been told that under no circumstances was he or any other staff member to warn the women involved that the man was HIV-positive because of issues of privacy and possible legal action by the man. To protect one person's autonomy and rights, the rights - and perhaps in the long run lives - of other persons were to be sacrificed.

The Perversion of Autonomy is about this "big trouble," and it is an excellent introduction to the issues involved in "the intersection of interdependence and autonomy, of individual rights and mutual responsibility." The books thesis is that "the morality of interdependence and mutual responsibility has been clashing with respect for autonomy with increasing frequency and harshness for the past thirty years, and that autonomy has won in these clashes too often.... The autonomy of the individual represents Americas greatest moral strength and now, peculiarly, its most insidious moral danger.... There can be no free society without individual autonomy, and there can be no sustainable society that rests on autonomy alone."

Gaylin and Jennings argue that in the name of autonomy, "mentally ill patients were granted their freedom to defecate, urinate, sleep, starve, freeze, murder, and be murdered in the streets of our larger cities." The authors decry the abuse Lorena Bobbitt, who cut off her husband's penis, or the Menendez brothers, who murdered their parents. Coercion is sometimes necessary, they conclude, "and the only real question is what kind of coercion it will be and on what psychological foundations it will rest." Newborn babies should be screened for AIDS because "society not only has a right to protect the unknowing from infection, it has an obligation to do so." And they defend the drug testing and treatment of pregnant women.

Liberals in particular revile coercion; as the authors note, its "one of the negative words in our social vocabulary that possesses a magic power of moral disapprobation by its mere utterance." Gaylin and jennings unfortunately give short shrift to two of the major influences on the perversion of autonomy: the American Civil Liberties Union (ACLU) and psychoanalytic theory. The ACLU is described in a single sentence as having played "the central moral role of holding that banner [autonomy] aloft;" it surely deserves more than a sentence. Similarly, Freudian theory, psychoanalysis, and its multiple offshoots in contemporary culture that promote individual autonomy over the rights of others deserve close scrutiny for their pernicious influence. Gaylin, himself a trained psychoanalyst, is understandably reluctant to undertake this investigation, but the omission is unfortunate.

Such delicate treading aside, this book is significant because, within the confines of traditional liberal ideology, it is politically incorrect. Gaylin and Jennings assert that "liberals have been making a serious mistake in the past few years when they have concluded that this pluralism [of American society] precludes any serious consideration of the individual or the common good." In fact much of The Perversion of Autonomy would fit comfortably into the Heritage Foundation, Manhattan Institute, or other conservative think tanks. There is an emerging consensus from all points on the political spectrum that autonomy in American society has run amok, and this book nicely demonstrates some of the common ground on which specific solutions can be built. (Truth-in-reviewing laws require me to add that in their book the authors praise one of my own books)

The Perversion of Autonomy does have shortcomings. The portion of the book devoted to actual case studies is disappointingly meager compared to that devoted to historical and philosophical overviews. In particular, I would have liked to hear the authors' specific recommendations on how coercion should be structured and implemented in the examples they discuss. For example, for the mentally ill homeless, do they support the policy implemented by New York's former mayor Ed Koch to have the homeless mentally ill individuals involuntarily hospitalized for trials of medication? How long should such a person be held for such trials? Do they support outpatient commitment laws for such individuals? Injectable medications? Urine testing to ensure medication compliance for oral medications? A national law to ensure enforcement of outpatient commitment if the committed individual goes across state lines? These are the real-life issues that must be addressed when coercive policies are actually implemented. The authors give general guidelines for thinking about such questions, but it would have been better to provide some illustrative, detailed workings-through.

Also missing from the discussion are comparisons of the use of coercion in other medical problems. For example, we do not let individuals with Alzheimer's disease wander in the snow without adequate footwear, because we realize that they will get frostbite. We provide structure, including locked doors when needed, because we realize that they have a disease of their brain. Yet when we think about using coercion for individuals with other brain diseases such as schizophrenia or bipolar disorder, we encounter much resistance. Similarly, our society had no problem in years past in isolating and, when necessary, forcibly detaining individuals with tuberculosis, smallpox, or other infectious diseases that may be fatal. When similar mechanisms are proposed for individuals with AIDS who are intentionally exposing other individuals to the virus, we also encounter great resistance. Discussing such comparisons would have been helpful.

Despite such shortcomings, The Perversion of autonomy is an important book. The authors state that "we have tried to write a book that is questioning rather than ideological," and they have succeeded. It can be viewed, like many books, as a glass half full or half empty. Its contribution to discussion of the issues of autonomy and community should ensure that it will be viewed in retrospect as half full, and when one is thirsty, that is often enough.