It will come as no surprise to those familiar with O'Neill's work that she finds the virtual idolization and tyranny of autonomy in the field of bioethics very troubling. In Autonomy and Trust in Bioethics, O'Neill addresses the problematic nature of ‘reproductive autonomy’ and ‘patient autonomy'’, both of which are species of ‘individual autonomy’, a concept she distinguishes from ‘principled autonomy’. O'Neill entreats those engaged in moral discourse to detach themselves from rights language and morally deficient notions of individual autonomy and instead embrace principled autonomy and the language of obligation. She points out that we are ‘likely to reach a convincing account of human rights more directly by way of an account of human obligations’ (p. 77). This is a tried and true theme for O'Neill, but in this work we find an increased sense of urgency to follow through with the prescribed shift in focus, as well as a special concern about what appears to be an inverse relationship between the expansion of individual autonomy and the tendency to trust other individuals and institutions. Along these lines, she notes that ‘from the patient's point of view . . . the most evident change in medical practice in recent decades is the loss of a context of trust rather than any growth of autonomy’ (p. 20). Because of the complexity of relationships of trust, however, O'Neill doubts that merely increasing trustworthiness via a commitment to principled autonomy will eliminate the pervasive mistrust. Nonetheless, since principled autonomy requires us to act in accordance with only those principles we can will for all other moral agents, it at least ‘provides a basis for relations of trust’ (p. 97) and thus constitutes a step in the right direction.

O'Neill explores the problem of diminished trust as it relates to many areas of health care and health policy decisions, including the relevance of trust to genetic screening programmes, the auditing of public health policy-makers, the process of informed consent, and the communication of health-related information to the public. Though she provides no empirical evidence of a causal connection between the heightened emphasis on individual autonomy and the diminishment of trust, a relationship between these two phenomena is probable given that individual autonomy is merely the ‘capacity for independent decisions and action’ (p. 23) and requires no commitment to basic moral principles. O'Neill illustrates this point when she reminds the reader that ‘Alcibiades was splendidly autonomous, and betrayed all the trust placed in him’ (p. 24). Unlike principled autonomy, which requires the rejection of coercion, deception and other ‘tempting principles’ (p. 86), individual autonomy requires neither rejection of these principles nor fulfilment of obligations, much less beneficence toward others; hence it is ‘constantly in tension with relations of trust’ (p. 97). People therefore lack good reasons to trust other individuals or institutions and tend to place trust haphazardly, which results in misplaced trust as well as misplaced mistrust – two problems O'Neill also addresses in depth in this book.

So, why the veneration of individual autonomy? O'Neill speculates that our ‘deeper reasons for prizing individual autonomy lie in its importance in making choices about . . . reproduction and . . . genetics’ (p. 48). Because the concepts of individual autonomy, a ‘right to privacy’ and a ‘right to choose’ became inextricably linked ‘in the battle against paternalism in reproductive medicine’ (p. 53), many have come to view not only decisions to avoid procreation but also decisions to procreate as private expressions of their individuality. O'Neill agrees that an individual's ability to limit procreative activity does expand one's range of choices in life but finds the notion of a distinct species of ‘reproductive autonomy’ dubious and notes that the concept becomes particularly strained when its proponents attempt to apply it to decisions to procreate, especially when assisted reproductive technologies are required to make it happen (pp. 52ff.). Individual autonomy is an inappropriate basis for procreative decision-making, given that the focus should be on fulfilling obligations towards others – in particular, offspring – not on self-expression or self-determination. Nonetheless, the primacy of individual autonomy has become deeply rooted in the realm of human reproduction and has spread like a kudzu weed to other areas of medical practice and bioethical discourse.

Ultimately, however, this ‘triumph of autonomy’ is anything but a coup for the field of bioethics, the medical profession, or relations of trust in general. Instead, informed consent – the supposed custodian of autonomy – has emerged as the great victor and is often treated as the final arbiter in determining the moral status of transactions between physicians and their patients. Despite the widespread penchant for treating informed consent as both necessary and sufficient for the moral soundness of actions in the health-care setting, O'Neill clearly shows that it is neither. She also provides the reader with compelling reasons to share her scepticism regarding the very possibility of genuine fully informed consent. She contends that ‘because of the vulnerability and weakness of most patients’, informed consent procedures are probably more inappropriate in the medical context than most other areas of life (p. 40). For many patients, especially those with the most confounding illnesses and injuries, informed consent requirements have become more of a curse than a blessing. In their relatively vulnerable state, patients are called upon to digest increasing quantities of highly technical information and then to decide from among a myriad of treatment alternatives, while various ‘strangers at the bedside’ remind patients that it is ‘their decision’. O'Neill also exposes the unacceptable superficiality of informed consent by pointing out that what patients actually consent to is often different from that to which they believe they have consented. A patient, she reminds us, can consent only to a particular ‘description of a proposal for treatment’ (p. 43). Consequently, in cases where a physician feels that a course of treatment would promote the patient's well being, a euphemistic description may be offered so that consent will be forthcoming, and even in the absence of any motive to garner consent, one must still grapple with the referential opacity of consent and patients' ‘failure to grasp the consequences’ (pp. 43–4) of that to which they consent. In any case, it is doubtful whether a patient's consent constitutes a genuinely free choice that reflects her individuality and character, or that it should. After all, a patient's goal is usually the diminishment of pain and the removal of its underlying causes, not to showcase her ability to engage in a ‘demanding exercise of individual autonomy’ (p. 38).

As the field of bioethics enters a more self-reflective phase, there is good hope that more people working in the area will grasp the importance of O'Neill's critical examination of the obsessive focus on individual autonomy and come to recognize that its moral importance is far more limited than is currently thought. O'Neill prescribes a dramatic but necessary shift in emphasis aimed at preventing the continued neglect of other morally significant considerations, not a wholesale rejection of individual autonomy. In the end, individual autonomy should simply be removed from its pedestal so that it is allowed ‘its due place, but no more’ (p. 192).