Singularity and medicine: is there a place for heteronomy in medical ethics? Ignaas Devisch PhD 1 and Stijn Vanheule PhD 2 1 Professor, Department of Medical Sciences, Ghent University, Gent, Belgium 2 Professor, Department of Psychoanalysis and Clinical Consulting, Ghent University, Gent, Belgium Keywords heteronomy, patient autonomy, patient care, singularity, technology Correspondence Dr Ignaas Devisch Department of Medical Sciences University of Ghent de Pintelaan 185 9000 Ghent Belgium E-mail: Ignaas.Devisch@UGent.be Accepted for publication: 29 November 2013 doi:10.1111/jep.12110 Abstract Rationale, aims and objectives In medicine and in clinical practice, autonomy is opposed to heteronomy or paternalism. While autonomy comes down to free choice, independence or self-fulfillment, heteronomy or paternalism are associated with restraints from outside, lack of free choice or dependence. Despite several mediating concepts such as relational autonomy, this opposition stands firm in medical discourse. Methods and results Reflecting upon his own heart transplantation but also falling back upon the whole of his oeuvre, we want to analyze what the impact of Nancy’s thought can be on the concept of autonomy in medicine. As in Nancy’s theory, autonomy and heteronomy are intertwined, how then to understand the autonomous individual in a clinical context? Nancy developed in his book Corpus, the untranslatable French word ‘expeausition’ to express the exposure of surfaces to one another – playing on the term ‘exposition’: ‘peau’, in French, means skin. Skin is literally exposed to contact with another skin or surface. Such exposure and such contact is ‘world’ he argues, in the same way that a product exchange between two people is. Heteronomy therefore is constitutive for autonomy, not a restraint of it. Conclusions Analyzed from the work of French philosopher Jean-Luc Nancy, there is no such thing as autonomy because every ‘self’ or ‘I’ is always already intruded by something from outside. There is no autonomy without heteronomy, he argues and he therefore prefers to speak of an individual as being exposed to the outer world. Biomedical intrusion Today, it is almost impossible to envision a life that is not, in one way or another, exposed to modern biotechnology. For instance, in Western societies, it is difficult to imagine a person who does not maintain his or her life by way of some artificial means. We ingest antibiotics to treat infection; we receive a blood transfusion following trauma. Advances in medical research and technology promise to us a plethora of medicines, surgeries or any other medical act designed to ameliorate threats to and, as a result, prolong our life. In short, it would seem in today’s world that less and less of us live natural lives, or die natural deaths. Moreover, it appears quite possible to argue that living your life today requires an acknowledgement of biomedical intrusion, as Vos and Willems do [1]. While many examples of what Vos and Willems refer to as the ‘intruding nature’ of medical technology may be present in our day to day living, the transplanting of other people’s organs into one’s body may indeed be the most medically intrusive act of all [1]. In philosophical terms, technology is often understood as ‘heteronymous,’ that is, as coming from outside and as a threat to personal autonomy [2; M. De Kesel, unpublished]. For example, this can be found in the work of Heidegger [3], who believed that technology chains the human being and restricts his freedom. A strong emphasis on autonomy can also be found in medical ethics, albeit without the characteristic philosophical focus on heter- onomy [4]. Autonomy may be summed as an individual’s ability to make choices and to govern the self, free from outside influence. Autonomy is perceived as something that resides within the indi- vidual. It refers to people’s ability to make self-determined choices. Heteronomy, by contrast, is often thought of as an obli- gation or hindrance from outside that restricts individual freedom, and that subjects a person to external laws and restrictions [5]. Indeed, autonomy and heteronomy are often positioned as oppo- sites in that autonomy is often viewed as ‘good’, whereas heter- onomy is to be countered. Yet given the current evolutions in medical technology, which imply an increasing presence of ‘heteronymous’ factors in every- day life, we believe that the dichotomy between the positively appraised autonomy and negatively judged heteronomy needs to be revised. As modern existence is increasingly characterized by an ‘intruded’ autonomy, the time has come to reconsider the ways Journal of Evaluation in Clinical Practice ISSN 1365-2753 Journal of Evaluation in Clinical Practice (2014) © 2014 John Wiley & Sons, Ltd. 1