| I advance a novel conception of autonomy that I call "effective autonomy"---a conception designed to be genuinely action-guiding in bioethics. To set the stage, I review contemporary philosophical accounts, and demonstrate how an individual who is classified as autonomous on these accounts may fail to be effectively autonomous. As psychological research on the heuristics and biases approach illustrates, decision-making commonly fails to be rational because of the biases arising from bounded cognition. Decisions are uncoupled from autonomous interests.; Trust in the physician-patient relationship is a cornerstone of effective autonomy. I argue that intellectually responsible trust requires a minimal standard of reliability in terms of documented outcomes. Moreover, I contend that trust between patient and physician is legitimated just in case there is intellectually responsible trust in clinical and basic science researchers. Research on patient attitudes, however, has identified several features of the physician-patient interaction (e.g., eye contact, informal questions) that cue patient trust---and these features appear to be unrelated to the reliability of medical expertise. Fostering effective autonomy also requires continuing research into the cues for patient trust.; Effective autonomy depends on the well-calibrated application of evidence-based medicine, which in turn relies on medical research. For some time, equipoise has spurred debate about the appropriate standard for medical research. I defend a version I call "prospective equipoise" as the best ethical standard for research. Prospective equipoise is preferable to other standards because it more adequately protects the effective autonomy of patients as research subjects and is more likely to produce conclusions that will foster future effective autonomy.; Fostering effective autonomy will include debiasing techniques in the medical decision-making process. The paucity of research on the extent of biased decision-making in medicine (let alone strategies for debiasing) leaves me to make only provisional recommendations. For example, one seminal study identifies the overconfidence bias in medical practitioners recommending treatments to patients with cancer. A simple strategy for dealing with over-confidence is "consider the alternative." The precise value of the conclusions of social psychology for fostering effective autonomy will depend on the application of thirty years of research to medical decision-making. |
