Patient autonomy despite false beliefs? On the epistemic prerequisites for autonomous treatment decisions

Within debates on the epistemic preconditions of patient autonomy, scholarly attention has focused predominantly on the scope and weight of cognitive competencies, while the role of doxastic attitudes towards medical information have remained comparatively underexplored. Clarifying this issue is, however, of considerable importance when dealing with patients who, though competent and properly informed by the healthcare professionals, withhold belief in the medical facts presented to them. Are such self-imposed false believes compatible with autonomous decision-making and therefore demand respect, or do they undermine its epistemic foundation? Discussing two basic concepts of "understanding" as well as the resulting moral impasse between paternalism and arbitrariness, we propose a new direction of inquiry along two lines: First we interrogate a tacit assumption underlying the very notion of "self-imposed false beliefs" by discussing the question "Can we believe at will?". This discussion yields a promising account that emphasizes the importance of reasons-responsiveness, shifting the focus from the belief itself to the process of belief formation. We conclude that not the truthfulness or falsity of patients' beliefs is key but by the procedural quality of their development. By drawing on the Elaboration Likelihood Model, we are invoking psychological research that supports this claim. Secondly, in order to transfer these insights to the theory and practice of medical ethics, we distinguish two notions of autonomy based on their functions as (1) ideal philosophical concept and (2) basic status designation in real life. The paper argues that in the first realm the notion of reasons-responsiveness informs our assessment of false beliefs and strategies to enhance the "understanding" part of autonomy, entailing limited positive duties for healthcare professionals. At the same time, appealing to the relevance of a basic concept of autonomy in the realm of legally binding decisions we argue that the strong duty of non-interference with competent patient's decisions must prevail.