Relational conceptions of autonomy revisit themes that have become prominent in the broader literature in philosophy through the work of Charles Taylor (e.g., Taylor, 1985a, 1985b, 1989). 151–180), Oxford University Press, Oxford. Med Law Rev. In particular, we found that it is used as narrow lens to view aspects of medically assisted death [30, 47, 58, 61, 62, 73] or euthanasia [47, 56, 61]. Fourth, these individual conceptual schemes were considered as a whole to search for relationships that would produce a comprehensive overall response to our research questions. This scheme was iteratively evaluated and checked against previous QUAGOL steps in order to ensure that it was consistent. Ho A. Relational autonomy or undue pressure? Nurs Inq. 2017;77:1062. The most frequently represented countries were the USA (n = 10); Canada (n = 7); the UK (n = 6); and Belgium (n = 5). Health care professionals will require additional skills of effective communication and social dynamics [26, 27, 54, 58, 67, 73]. Our analysis of included publications revealed many notions closely aligned with the essence of what is called ‘relational autonomy’ in feminist and care ethics critiques, yet expressed using different terms. The place of autonomy in bioethics. Wardrope A. Authenticity and autonomy in deep-brain stimulation. (or it takes at least two to tango). PubMed Google Scholar. The full text of this article hosted at iucr.org is unavailable due to technical difficulties. A conceptual scheme is a synthetic frame where different concepts that appear relevant to answer the research questions are presented and interrelated with each other (an example of a conceptual scheme is provided as Additional file 1). On patient autonomy and physician responsibility in end-of-life care. Nonetheless, discussions of patient autonomy in the bioethics literature, which focus on individual patients making particular decisions, neglect the social structure within which health-care decisions are made. The perspectives of the dominant Western ethical theories, have dominated the concepts of autonomy and informed consent for many years. Dierckx de Casterlé B, Gastmans C, Bryon E, Denier Y. QUAGOL: a guide for qualitative data analysis. Group B focused the search on end-of-life topics. Taboada P, Bruera E. Ethical decision-making on communication in palliative cancer care: a personalist approach. If relationships of care and interdependence are valuable and morally significant (cf. Nurs Ethics. 1999;25(6):522–7. Among these models are systematic reviews of argument-based literature, which aim to present up-to-date comprehensive overviews of the ethical arguments and underpinning concepts identified in relation to a certain topic [18]. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Relational Autonomy: Feminist Perspectives on Automony, Agency, and the Social Self Professor of Philosophy and Director of the Research Centre for Agency Values and Ethics Catriona MacKenzie , Catriona Mackenzie , Natalie Stoljar , Lecturer in Philosophy Natalie Stoljar The final aspect relates to deficiencies in current practices, laws, and policies. Respect for autonomy is widely accepted as a cornerstone in end-of-life care ethics, but mainstream interpretation of this idea has received many critiques as well. Fifty publications met our inclusion criteria. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. Hast Cent Rep. 1972;1:5–7. Relational autonomy in breast diseases care: a qualitative study of contextual and social conditions of patients’ capacity for decision-making. Publications also addressed many practical challenges when applying relational autonomy to end-of-life care ethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around. Thus, a pluralistic ethics needs to be developed and refined further [25, 38, 57, 60, 64]. volume 20, Article number: 76 (2019) Shih P, Rapport F, Hogden A, Bierbaum M, Hsu J, Boyages J, et al. In fact, the latter was conceptualised as a ‘mirror’ of individualistic autonomy. Authors taking a feminist stance, such as Donchin, preferred to argue for a strong conception of relational autonomy. The first two sections present and then criticize a simplified interpretation of individualistic autonomy, against which relational autonomy is often developed. New York: Oxford University Press; 2000. The database search was performed in February 2019, using no filters or data restrictions. We followed the guidelines detailed in Peer Review of Electronic Search Strategies (PRESS) [22], and our search process and reporting followed the statement and flowchart of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [23] (Fig. We analysed relevant articles in medical, philosophy, and theology fields. Swiss Med Wkly. J Clin Epidemiol. We found that authors insisted on the notion of an embodied self [26, 42, 45, 62, 69, 73], which entails vulnerability [25, 28, 30, 35, 36, 39, 40, 42, 47, 50, 52, 55, 58, 68,69,70, 73, 74] and dependency on others’ care [29, 36, 37, 45, 47, 49, 50, 52, 58, 64, 68]. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Kon AA. Hence, whenever the family or healthcare professionals tried to overrule the patient’s autonomy, even when looking out for their best interests, authors considered this to be an example of unwarranted paternalism, pressure, coercion, or manipulation [50, 55, 73]. They considered autonomy to be expressed along a continuum, one whose value can vary in the dynamic process of care [36, 39, 42, 44, 50, 51, 57, 69, 71]. This paper draws upon my experience conducting bioethics research related to clinical trial decision-making to develop a systematic method for applying relational autonomy as a theoretical lens to qualitative health research. However, some challenges are also being faced and need to be understood. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username, By continuing to browse this site, you agree to its use of cookies as described in our, I have read and accept the Wiley Online Library Terms and Conditions of Use. This should in turn lead to better decision-making in real-life situations. Terms and Conditions, Secondly, it has to be free from external interference of health professionals, relatives, or the society in general [28, 30, 33, 37, 39]. Baker FX, Gallagher CM. In order to assess our criteria consistency, abstract screening was performed independently by the first (CGV) and third author (CG). someone threatens my life) or if I act merely based on what makes me happy in the moment (e.g. Laura Williamson - 2014 - American Journal of Bioethics 14 (6):4-16. Empirical research about relational autonomy in this field highlighted potential changes in the doctor-patient relationship and in physicians’ responsibility towards patients and their families [17]. 1. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. [30, 42,43,44, 49, 51, 56, 58, 61, 65, 70]. Thus, in conceptualising human beings, tension is maintained: no relationality without individuals; no individuality without relations. This paper draws upon my experience conducting bioethics research related to clinical trial decision-making to develop a systematic method for applying relational autonomy as a theoretical lens to qualitative health research. By way of illustration, Ikonomidis and Singer’s article is an example of a nuanced understanding of individual autonomy from a liberal perspective, far removed from the portrayal depicted in relational critiques [41]. Louis Janssens, the founder of this tradition, had previously distinguished eight dimensions of the human person [79]. 2014;133(Suppl 1):S16–23. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics. The importance of particular relationships, such as family, friends, and communities, was commonly neglected by individualistic theories [25, 27, 32, 37]. Especially for end-of-life ethics, the need for a relational turn in the understanding of autonomy has led to a growing number of publications on shared decision-making [10,11,12,13] and advance care planning [14,15,16]. Our synthesis describes a relational understanding of human beings in terms of connectedness [29, 37, 41, 43, 44, 53, 58,59,60] and interdependency [28, 32, 38, 58, 59, 63, 65]. A trend of recent publications in ethical literature reveals a growing awareness of the relational dimension of healthcare, in general, and in end-of-life care practices, in particular. Some authors pointed out that futile treatment and therapeutic obstinacy may result from collective pressure [27, 43, 44]. I then consider how understanding bioethics and science fiction as interrelated discourses can be the basis of a methodology for inquiry into relational autonomy in the context of biotechnologies and medicine. 2011;9(2):203–10. First, we introduce a simplified interpretation of individual autonomy in mainstream bioethics, as derived from the analysis of the included publications. To be included in the systematic review and appraisal, candidate articles had to meet all inclusion criteria and have no exclusionary one. 2018 Mar;32(3):184-192. doi: 10.1111/bioe.12424. Louvain Stud. 1997;44(5):681–92. bioethics [7, 8]. In this regard, following Broeckaert’s theoretical framework [20], we found that the majority of articles focussed on curative or life-sustaining treatment (n = 32). Int J Law Context. Planning ahead with dementia: what role can advance care planning play? A familial advance directive is a document ‘signed by the patient together with the family’ that ‘communicate [s] the wish of the family as a whole’ about the patient’s advance care planning and the dying process [37]. Relational autonomy is an ethical concept that links to a variety of ethical approaches and therefore cannot be exclusively characterised by a single approach. [33] explicitly based their theoretical foundations on Jürgen Habermas’ communication theory and dialogical ethics. 1. Review and understand the ethical principles of autonomy and beneficence. Concretely, this model may permit a caregiver to invade the patient’s privacy, for example, in order to achieve a shared and negotiated total good. Brauer S. Die Autonomiekonzeption in Patientenverfügungen–die Rolle von Persönlichkeit und sozialen Beziehungen. An individualistic understanding of autonomy has been criticized from different theoretical standpoints. Tse CY, Chong A, Fok SY. Asian Bioethics Rev. and you may need to create a new Wiley Online Library account. Principles of biomedical ethics. Other approaches consisted of care ethics (n = 10); ethical multiculturalism (n = 8); phenomenology (n = 8); personalist ethics (n = 5); relational ethics (n = 4); and virtue ethics (n = 1). This resulted mostly in an impoverished conceptualisation of relational autonomy, since an antithetical conceptualisation can always be presented without any deliberation or analysis. 2016;17(1):72. Completing this analysis was important, because it may illuminate a path towards better decision-making in end-of-life care healthcare. McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. The starting point of this work is our systematic review on relational autonomy in end-of-life literature [].This review showed that relational autonomy is used as a negative concept, one that reacts against the ‘mainstream interpretation’ Footnote 1 of the principle of respect for autonomy. An alternative model of autonomy, relational autonomy, highlights the social context within which all individuals exist and acknowledges the emotional and embodied aspects of decision-makers. Ethik in der Medizin. Some articles considered the first two levels of involvement to be valid expressions of relational autonomy [43, 44, 46], but the third level to be a case of ‘compromised autonomy’ [29, 46]. The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. Healthcare professionals¸ for their part, were said to have a certain responsibility towards the needs of the patient and the family [31, 45, 52, 54, 68, 73]. Limits to relational autonomy—the Singaporean experience. Finally, some articles employed more remote notions in order to express similar insights. First, literature on relational autonomy tends to be more a ‘reaction against’ an individualistic interpretation of autonomy rather than be a positive concept itself. AU - Walker, Mary Jean. Second, we advocate engaging in fruitful dialogue between different and complementary approaches to the interpretation of relational autonomy. Relational Autonomy: Feminist Perspectives on Autonomy, Agency and the Social Self(pp. Sharing death and dying: advance directives, autonomy and the family. 2003;9(2):285–98. 2013;5(1):39–57. Thus, in many articles, authors started by portraying individual autonomy as a basic principle in end-of-life care ethics. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Relational theorists have highlighted the importance of emotions, imagination, and non-verbal communication, as essential elements of human decision-making [27, 28, 32, 45, 48, 52, 54, 68, 69, 73]. On the basis of this supposition, the origins of an individualistic interpretation of autonomy were presented. Nevertheless, our analysis did not find a consensus on the definition of relational autonomy. Both of these practices in end-of-life care are unsatisfactorily conceptualised in the classical individualistic framework. We performed a systematic review of argument-based literature in order to better understand the meanings, foundations, and uses of relational autonomy in the field of end-of-life care ethics. Drawing upon this classical work, Selling thoughtfully changes the order of presentation of these eight dimensions: he starts from relationality to end up at the uniqueness of the human person. First, decision-making was better depicted as being a dynamic ongoing process rather than an isolated discrete event [25, 36, 69]. Examining American bioethics: its problems and prospects. A majority of the publications used feminist ethics approaches or primarily drew upon feminist sources (n = 21). Relatives were encouraged to participate in decision-making [25, 30, 40, 46, 51, 53, 57, 66, 69, 72]. Relational ethicists are especially sensitive to discriminatory issues. They denounced the potentially ‘ableist’ ideology that is underpinned by a capacity-centred approach to autonomy. The third and fourth inclusion criteria were: (3) publication is considered to be in the argument-based literature, which is an article using ethical concepts derived from current or traditional ethical theories in order to argue for a position or conclusion [21]; (4) must be published in English, French, German, Portuguese, or Spanish. A thorough consideration of our results uncovers some potential clues about how to translate theory into practice regarding end-of-life decisions. 1081, ... [Patient autonomy and right to choose medical treatment without blood transfusion given current Brazilian civil and constitutional precepts.] Even if the way to implement this dialogical stand varies from one author to another, the practical proposal that reached broader consensus was shared decision-making. ... Relational Autonomy and Support for Autonomy: A Commentary on "Relational Autonomy as a Theoretical Lens for Qualitative Health Research" by Jennifer A. H. Bell; Sylvia Burrow ; pp. Selling J. The purpose of Group A concepts was to focus on the use of relational autonomy through technical concepts and common expressions. Sociol Health Illn. bioethics literature and its incongruence with patient-centered care); (3) We pro - pose relational autonomy as an alternate formulation of autonomy that health-care professionals would recognize as consistent with patient-centered care; (4) We argue that theorists explicitly adopt relational autonomy as an essential component Flow chart showing the electronic search, identification, and selection process for the reviewed articles [23]. Fourth, this new conceptualisation of relational autonomy is applied to scenarios of clinical practice and moral judgment in end-of-life situations. , Naulaers G, Vanhole C, Gøtzsche PC, Ioannidis JPA, et al note, due the... 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Topic of relational autonomy: when families pressure patients to change their wishes collatéraux des traitements oncologiques point...