Introduction
Autonomy can be defined as “self-governance” and is derived from the ancient Greek words auto (self) and nomos (law). It is an important concept in Western thought, namely it is a central part of Mill’s libertarianism and Kantian deontological ethics. Moreover, autonomy is foundational in medical ethics and bioethics and figures as one of Beauchamp and Childress’s famous 4 Principles, along with beneficence, non-maleficence and justice. Mackenzie (2004) outlines four primary interpretations of autonomy: decisional, conscientious, libertarian, and relational.
Decisional autonomy is centered around promoting informed decision making for each individual. Key aspects of this notion of autonomy include voluntariness and the freedom from external or internal controlling influences.
The conscientious interpretation understands autonomy as fidelity to one’s goals, standards, principles and norms. It emphasizes individual responsibility towards oneself so decisions can fit one’s worldview and way of life, as well the corresponding accountability required to others.
Libertarian autonomy on the other hand equates autonomy with negative liberties and the right to be free from interference from others or the state in one’s personal life. Respecting autonomy in the libertarian notion is to maximize individual choice and keep any interference with personal choice to a strict minimum.
Finally, relational autonomy is an “umbrella term” born from the feminist perspective in philosophy as a response to concerns of social injustice and oppression of many groups. This interpretation highlights the complex and multidimensional nature of autonomy and notes that to evaluate its full exercise requires assessing interpersonal dynamics, social institutions, etc… It shares a richer account of the competence required for autonomy by understanding it as a socially constituted capacity. Therefore, approaching autonomy from a relational interpretation avoids several practical limitations found in the above listed approaches, and leaves room to address the role relationships, ethnic and cultural background, factors beyond cognitive capacity, and lived experience can all have on one’s autonomy. (Gómez-Vírseda et al 2020)
As such, the relational interpretation of autonomy is more aware of human vulnerability and dependency in its varying forms and degrees and can be very useful to resolve issues and aid patients in the healthcare context.
Assigned Readings
Christman, J. (2014). Relational Autonomy and the Social Dynamics of Paternalism. Ethical Theory and Moral Practice, 17(3), 369-382. https://doi.org/10.1007/s10677-013-9449-9
Thesis: Christman explores the commonly held standard of paternalism as interference in a model where paternalist and subject are evaluated separately in discourse around autonomy. The rhetoric around autonomy should not merely be one of respect but of valuing and that attitudes and actions of the paternalist should also be considered in facilitating the autonomy of patients.
Lewis J. (2019). Does shared decision making respect a patient’s relational autonomy?. Journal of evaluation in clinical practice, 25(6), 1063–1069. https://doi.org/10.1111/jep.13185
Thesis: Lewis challenges the view that shared decision making (SDM) models of physician-patient relationship respect relational autonomy, rather he argues that some obligations of relational autonomy are neglected in SDM accounts.
Discussion Questions
- How does the relational approach differ from the more “standard conception” of autonomy?
- How does procedural relational autonomy differ from substantive relational autonomy?
Key Concepts
- Substantive approach to relational autonomy
- Interpersonal and social relations must be normatively acceptable ie. there should be no reason in principle that one autonomously chose roles of oppression, subservience, and deference.
- Involves commitment to substantive ideals of egalitarianism, independence, and/or ownership.
- Proceduralist approach to autonomy
- Competency and authenticity are necessary conditions.
- Subject’s decisions should be respected if demonstrating competency and authenticity.
- Weak paternalism – interference to an agent’s autonomy to help them attain or find better ends to their means.
- Strong paternalism – interference to an agent’s autonomy aimed to guide them to achieve different ends.
- Pure paternalism – interference solely motivated by the subject’s good.
- Impure paternalism – interference motivated by aims other than merely the subject’s good.
- Soft paternalism – interference justified based on a subject’s temporary impairment/inability to act autonomously. Once the cause of the inapt judgement is resolved the subject decision should be in accord with the paternalist interference.
- Hard paternalism – interference regardless of a subject’s consent, aptitude, and competence to reach a decision.
References and Additional Resources
Stoljar, N. (2018) Feminist Perspectives on Autonomy. The Stanford Encyclopedia of Philosophy. Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/win2018/entries/feminism-autonomy/>.
Dworkin, G. (2020) Paternalism. The Stanford Encyclopedia of Philosophy. Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/fall2020/entries/paternalism/>.
Peterson, A., Karlawish, J., & Largent, E. (2021). Supported Decision Making With People at the Margins of Autonomy. The American journal of bioethics : AJOB, 21(11), 4–18. https://doi.org/10.1080/15265161.2020.1863507
Dove, E. S., Kelly, S. E., Lucivero, F., Machirori, M., Dheensa, S., & Prainsack, B. (2017). Beyond individualism: Is there a place for relational autonomy in clinical practice and research?. Clinical ethics, 12(3), 150–165. https://doi.org/10.1177/1477750917704156
Gómez-Vírseda, C., de Maeseneer, Y., & Gastmans, C. (2020). Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities. BMC medical ethics, 21(1), 50. https://doi.org/10.1186/s12910-020-00495-1
Gómez-Vírseda, C., de Maeseneer, Y. & Gastmans, C. (2019). Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Med Ethics 20, 76. https://doi.org/10.1186/s12910-019-0417-3
“Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self” Mackenzie and Stoljar (eds)