Relational autonomy: lessons from COVID-19 and twentieth-century philosophy

Abstract

COVID-19 has turned many ethical principles and presuppositions upside down. More precisely, the principle of respect for autonomy has been shown to be ill suited to face the ethical challenges posed by the current health crisis. Individual wishes and choices have been subordinated to public interests. Patients have received trial therapies under extraordinary procedures of informed consent. The principle of respect for autonomy, at least in its mainstream interpretation, has been particularly questioned during this pandemic. Further reflection on the nature and value of autonomy is urgently needed. Relational autonomy has been proposed as an alternative account of autonomy that can more adequately respond to contemporary ethical issues in general and to a pandemic such as the one we are currently facing in particular. As relational autonomy is an emerging notion in current bioethics, it requires further consideration and development to be properly operationalized. This paper aims to show how six different philosophical branches––namely, philosophy of nature, philosophical anthropology, existential phenomenology, discourse ethics, hermeneutics, and cultural anthropology––have incorporated the category of relation throughout the twentieth century. We first delve into primary philosophical sources and then apply their insights to the specific field of medical ethics. Learning from the historical developments of other philosophical fields may provide illumination that will enable bioethics to experience a successful “relational turn”, which has been partially initiated in contemporary bioethics but not yet achieved.

Cancer prevention in people experiencing homelessness: ethical considerations and experiences from the CANCERLESS project

“…Autonomy has a strongly individualistic character, underscoring the decisions of people regardless of their circumstances, that is, their ability to exclusively make a choice without coercion or to make an informed decision. This notion has recently been questioned by bioethics following the impacts of the COVID-19 pandemic ( 39 ). Both concepts lack the relational sense that autonomy should have, considering the influence of social determinants on decision-making ( 40 ).…”

Using symbiotic empirical ethics to explore the significance of relationships to clinical ethics: findings from the Reset Ethics research project

“…The roots of this individual focus of a clinician’s professional attention lie in the Greek medicine tradition, reflected particularly in the Hippocratic Oath, which remains the basis of the (current) World Medical Association’s Declaration of Geneva, where similar wording appears [ 13 ]. Furthermore, in clinical ethics the doctor-patient relationship is centred on an understanding of patients as rational, self-interested, transparent individuals, guided by their conscious personal wishes, making decisions for and by themselves [ 14 ]. Clinical ethics is thus predominantly focused on a HCP-patient dyad, with the ethical course of action aligned, as far as possible, with the preferences and values of the individual (autonomous) patient [ 15 ].…”

“…In the healthcare context, patients live not ‘in a cocoon’ but in a relational, social and cultural environment that conditions and limits their healthcare decision-making [ 14 ]. This was starkly evident during the COVID-19 crisis, when many families suffered because they were unable to visit loved ones or, worse, to be with loved ones as they died.…”

“…This was starkly evident during the COVID-19 crisis, when many families suffered because they were unable to visit loved ones or, worse, to be with loved ones as they died. Carlos Gómez‑Vírseda and Rafael Usanos, reflecting on the legacy of the pandemic, have argued that relationality should be ‘integrated into the heart of bioethical theory’ [ 14 ]. Charting the development of philosophical accounts of relationality in the social sciences (the philosophical branches of cultural anthropology, philosophy of nature, and discourse ethics), and the evolution of phenomenology (philosophical anthropology, existential phenomenology and hermeneutics), Gómez‑Vírseda and Usanos distil several key insights into the relational model of autonomy they suggest [ 14 ].…”

“…Carlos Gómez‑Vírseda and Rafael Usanos, reflecting on the legacy of the pandemic, have argued that relationality should be ‘integrated into the heart of bioethical theory’ [ 14 ]. Charting the development of philosophical accounts of relationality in the social sciences (the philosophical branches of cultural anthropology, philosophy of nature, and discourse ethics), and the evolution of phenomenology (philosophical anthropology, existential phenomenology and hermeneutics), Gómez‑Vírseda and Usanos distil several key insights into the relational model of autonomy they suggest [ 14 ]. First, that the biocultural human being exists within relations to and with other humans, which means that cultural and social relationships are fundamental to human existence [ 22 ].…”