Dove, E. S., Kelly, S. E., et al. (2017).
Clinical Ethics, 12(3), 150–165.
https://doi.org/10.1177/1477750917704156
Abstract
The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangible and positive impact on clinical practice and research. These solutions leave the ultimate decision to the person most affected, but encourage and facilitate the consideration of this person’s care and responsibility for connected others.
From the Discussion section
Together, these cases show that in our quest to enhance the practical value of the concept of relational autonomy in healthcare and research, we must be careful not to remove the patient or participant from the centre of decision-making. At the same time, we should acknowledge that the patient’s decision to consent (or refuse) to treatment or research can be augmented by facilitating and encouraging that her relations to, and responsibility for, others are considered in decision-making processes. Our case studies do not suggest that we should expand consent requirements to others per se, such as family members or community elders – that is, to add the requirement of seeking consent from further individuals who may also be seen as having a stake in the decision. Such a position would undermine the idea that the person who is centrally affected by a decision should typically have the final say in what happens with and to her, or her body, or even her data. As long as this general principle respects all legal exceptions (see below), we believe that it is a critical underpinning of fundamental respect for persons that should not done away with. Moreover, expanding consent or requiring consent to include others (however so defined) undermines the main objective of relational autonomy, which is to foreground the relational aspect of human identities and interests, and not merely to expand the range of individuals who need to give consent to a procedure. An approach that merely extends consent requirements to other people does not foreground relations but rather presumptions about who the relevant others of a person are.
