Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature

Abstract

BackgroundRespect for autonomy is a key concept in contemporary bioethics and end-of-life ethics in particular. Despite this status, an individualistic interpretation of autonomy is being challenged from the perspective of different theoretical traditions. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Along these lines, the notion of relational autonomy is attracting increasing attention in medical ethics. Yet, others argue that relational autonomy needs further clarification in order to be adequately operationalised for medical practice. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics.MethodsUsing PRESS and PRISMA procedures, we conducted a systematic review of argument-based ethics publications in 8 major databases of biomedical, philosophy, and theology literature that focused on relational autonomy in end-of-life care. Full articles were screened. All included articles were critically appraised, and a synthesis was produced.ResultsFifty publications met our inclusion criteria. Twenty-eight articles were published in the last 5 years; publications were originating from 18 different countries. Results are organized according to: (a) an individualistic interpretation of autonomy; (b) critiques of this individualistic interpretation of autonomy; (c) relational autonomy as theoretically conceptualised; (d) relational autonomy as applied to clinical practice and moral judgment in end-of-life situations.ConclusionsThree main conclusions were reached. First, literature on relational autonomy tends to be more a ‘reaction against’ an individualistic interpretation of autonomy rather than be a positive concept itself. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Second, relational autonomy is a rich and complex concept, formulated in complementary ways from different philosophical sources. New dialogue among traditionally divergent standpoints will clarify the meaning. Third, our analysis stresses the need for dialogical developments in decision making in end-of-life situations. Integration of these three elements will likely lead to a clearer conceptualisation of relational autonomy in end-of-life care ethics. This should in turn lead to better decision-making in real-life situations.

Reassessing advance care planning in the light of covid-19

“…Heightened public and professional interest provides an opportunity to establish a more nuanced, relational approach to choice, founded on co-creating shared narratives 10. This reflects existing best practice which recognises that advance care planning is an important facilitator of meaningful conversations, providing support through the experiences of living and dying with frailty.…”

“…Such conversations help to shape a jointly constructed life story that gives meaning and context to decisions and informs ongoing person centred care 10. The importance of this approach to older people is shown by their high prioritisation of not being a burden to family, a goal that the process of advance care planning can help to achieve 11.…”

“…The importance of this approach to older people is shown by their high prioritisation of not being a burden to family, a goal that the process of advance care planning can help to achieve 11. Thus individuals do not act alone; rather, they consider the priorities and concerns of those around them 51012. This is reflected in a relational model of autonomy: decisions are situated within social contexts, and social relationships enhance autonomy 10…”

“…Thus individuals do not act alone; rather, they consider the priorities and concerns of those around them 51012. This is reflected in a relational model of autonomy: decisions are situated within social contexts, and social relationships enhance autonomy 10…”

Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities

“…However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized. In 2019, we published a systematic review of argument-based literature that focused on the meaning, foundations, and uses of relational autonomy in end-oflife care ethics; this analysis led to three conclusions [24]. First, interpretations of relational autonomy tend to be more of a reaction against an individualistic account of autonomy rather than a positive concept that stands on its own.…”