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Lee SC, Shih CY, Chen ST, Lee CY, Li SR, Tang CC, Tsai JS, Cheng SY, Huang HL. Factors Contributing to Non-Concordance Between End-of-Life Care and Advance Care Planning. J Pain Symptom Manage 2024:S0885-3924(24)00657-2. [PMID: 38479538 DOI: 10.1016/j.jpainsymman.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/24/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
CONTEXT Despite making do-not-resuscitate or comfort care decisions during advance care planning, terminally ill patients sometimes receive life-sustaining treatments as they approach end of life. OBJECTIVES To examine factors contributing to nonconcordance between end-of-life care and advance care planning. METHODS In this longitudinal retrospective cohort study, terminally ill patients with a life expectancy shorter than six months, who had previously expressed a preference for do-not-resuscitate or comfort care, were followed up after palliative shared care intervention. An instrument with eight items contributing to non-concordant care, developed through literature review and experts' consensus, was employed. An expert panel reviewed electronic medical records to determine factors associated with non-concordant care for each patient. Statistical analysis, including descriptive statistics and the chi-square test, examines demographic characteristics, and associations. RESULTS Among the enrolled 7871 patients, 97 (1.2%) received non-concordant care. The most prevalent factor was "families being too distressed about the patient's deteriorating condition and therefore being unable to let go" (84.5%) followed by "limited understanding of medical interventions among patients and surrogates" (38.1%), and "lack of patient participation in the decision-making process" (25.8%). CONCLUSIONS This study reveals that factors related to relational autonomy, emotional support, and health literacy may contribute to non-concordance between advance care planning and end-of-life care. In the future, developing an advance care planning model emphasizes respecting relational autonomy, providing emotional support, and enhancing health literacy could help patients receiving a goal concordant and holistic end-of-life care.
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Affiliation(s)
- Shih-Chieh Lee
- Department of Family Medicine (S.-C.L.), Fu Jen Catholic University Hospital, No. 69, Guizi Road, Taishan District, New Taipei City, Taiwan
| | - Chih-Yuan Shih
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Shan-Ting Chen
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Ching-Yi Lee
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Shin-Rung Li
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Chia-Chun Tang
- Department of Nursing (S.-T.C.,C.-Y.L.,S.-R.L.,C.-C.T.), National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan; School of Nursing, College of Medicine (C.-C.T.), National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei, Taiwan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan
| | - Hsien-Liang Huang
- Department of Family Medicine, College of Medicine and Hospital (C.-Y.S., J.-S.T.,S.-Y.C.,H.-L.H.), National Taiwan University, No. 7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan.
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Takimoto Y, Shimanouchi A. Ethics Guideline Development for Neuroscience Research involving Patients with Mental Illness in Japan. Asian Bioeth Rev 2023; 15:365-375. [PMID: 37808451 PMCID: PMC10555971 DOI: 10.1007/s41649-023-00240-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/12/2023] Open
Abstract
This study aims to develop guidelines of key concepts and specific considerations to make the research more ethical when conducting neurological examinations and treatment interventions in mentally ill patients. We analyzed guideline development theory and literature, previous issues, and discussions with specialists of philosophy, medicine, sociology, and bioethics. The selection of research participants, drafting of intervention plans, and informed consent process were examined with reference to the dual burden; the minimal risk as a general rule of ethical allowance levels, assent and dissent to assess the individual's judgment capacity for consent, relational autonomy for personal consent with assistance by the proxy, and risk/benefit assessments. When conducting studies, this guideline requires that these three processes be set up appropriately on a case-by-case basis. Supplementary Information The online version contains supplementary material available at 10.1007/s41649-023-00240-x.
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Lasmarías C, Carrero V, Fernández-Bueno J, García-Llana H, Granero-Moya N, Júdez J, Pérez de Lucas N, Saralegui I, Velasco T. Advance Care Planning in Spain. Z Evid Fortbild Qual Gesundhwes 2023; 180:143-149. [PMID: 37442683 DOI: 10.1016/j.zefq.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 07/15/2023]
Abstract
In the last decade in Spain, an important push has been given to the development of health policies that define the framework of action in the care of people with advanced chronic diseases. Respect for the autonomy of the patient, shared decision-making processes and advance care planning (ACP) are recognized into health plans as a key aspect in chronic care, frailty, and palliative care. A few but significant number of institutions, local governments, and healthcare professionals from different regions of Spain have started a rationale and roadmap for a new twist in Spain's theoretical, ethical and policy development, promoting ACP implementation into public health care systems. In 2020, a working group founded in 2017, evolved into the "Spanish Association of Shared Care Planning" (AEPCA). The Shared Care Planning (SCP) concept grows up after the two international consensus Delphi studies in 2017 and pretends to shift from the framework of ACP programs to a person-centred care approach. In the last years, several experiences show how professionals are more sensible and interested on the ACP process, but it cannot be said, for now, that it has taken effect in the global Spanish health system. Even both ACP and SCP are being used simultaneously in Spain, each day more people and autonomous communities embrace renewed concept and foundations of SCP, supporting the work of AEPCA on spreading the value of this process into the care of people who are coping with chronic diseases, vulnerability, and frailty.
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Affiliation(s)
- Cristina Lasmarías
- Research Nursing at the Catalan Institute of Oncology, Barcelona, Spain.
| | - Virginia Carrero
- Dept. of Educational, Developmental, Social and Methodological Psychology in the Faculty of Health Science at the University of Jaume I of Castellón, Castelló de la Plana, Spain
| | - Júlia Fernández-Bueno
- Palliative Care Hospital Team, Hospital de la Princesa, Health Public Service, Madrid, Spain
| | - Helena García-Llana
- Psychology Department. Centro de Estudios Superiores Cardenal Cisneros (Universidad Complutense de Madrid). UNIR. Universidad Pontificia de Comillas, Madrid, Spain
| | - Nani Granero-Moya
- Nursing Department. Faculty of Health Sciences, University of Jaén, Jaén, Spain
| | - Javier Júdez
- Instituto Murciano de Investigación Biosanitaria Pascual Parrilla (IMIB), Servicio Murciano de Salud. Murcia, Spain
| | | | | | - Tayra Velasco
- Bioethics andNursing Department, Faculty of Health Sciences, Universidad Complutense de Madrid, Madrid, Spain
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4
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Miyashita J, Kishino M. Real-world experience implementing Advance Care Planning in the Asia-Pacific: ACP in Japan. Z Evid Fortbild Qual Gesundhwes 2023; 180:78-84. [PMID: 37516656 DOI: 10.1016/j.zefq.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 07/31/2023]
Abstract
Promoting Advance Care Planning (ACP) in the super-aged society of Japan has become increasingly important for supporting older adults to continue to live in the community until the end of life. To promote ACP further in Japan, Japanese family-centered decision-making and high-context culture need to be taken into account. Therefore, we describe the environmental and historical backgrounds surrounding ACP in Japan, and based on the results, introduce research and education programs regarding its implementation.
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Affiliation(s)
- Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching And Research, Fukushima Medical University, Fukushima, Japan.
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5
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Miyashita J, Shimizu S, Shiraishi R, Mori M, Okawa K, Aita K, Mitsuoka S, Nishikawa M, Kizawa Y, Morita T, Fukuhara S, Ishibashi Y, Shimada C, Norisue Y, Ogino M, Higuchi N, Yamagishi A, Miura Y, Yamamoto Y. Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning. J Pain Symptom Manage 2022; 64:602-613. [PMID: 36115500 DOI: 10.1016/j.jpainsymman.2022.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making. OBJECTIVES A consensus definition of advance care planning with action guideline adapted to Japanese society. METHODS We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan. RESULTS The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future. CONCLUSION Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.
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Affiliation(s)
- Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University.
| | - Sayaka Shimizu
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University
| | - Ryuto Shiraishi
- Department of Palliative Medicine, Kobe University School of Medicine
| | - Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital
| | | | - Kaoruko Aita
- Uehiro Division for Death & Life Studies and Practical Ethics, The University of Tokyo
| | | | - Mitsunori Nishikawa
- Department of Palliative Care, National Center for Geriatrics and Gerontology
| | | | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital
| | - Shunichi Fukuhara
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University; Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | | | - Chiho Shimada
- Faculty of Humanities and Social Science, Saku University
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Mieko Ogino
- Department of Neurology, Ichikawa Hospital, International University of Health and Welfare
| | | | - Akemi Yamagishi
- Department of Preventive Medicine and Public Health, School of Medicine, Keio University
| | - Yasuhiko Miura
- Department of General Medicine, The Jikei University School of Medicine
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University
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6
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Silva DS, Smith MJ. Is the Cure Worse than the Disease? The Ethics of Imposing Risk in Public Health. Asian Bioeth Rev 2022; 15:19-35. [PMID: 36106145 PMCID: PMC9463506 DOI: 10.1007/s41649-022-00218-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 01/11/2023] Open
Abstract
Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.
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Affiliation(s)
- Diego S. Silva
- grid.1013.30000 0004 1936 834XSydney Health Ethics, School of Public Health, University of Sydney, Sydney New South Wales, Australia
| | - Maxwell J. Smith
- grid.39381.300000 0004 1936 8884School of Health Studies, Western University, London Ontario, Canada
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7
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Lee JY. The limitations of liberal reproductive autonomy. Med Health Care Philos 2022; 25:523-529. [PMID: 35687215 DOI: 10.1007/s11019-022-10097-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 04/01/2022] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
Abstract
The common liberal understanding of reproductive autonomy - characterized by free choice and a principle of non-interference - serves as a useful way to analyse the normative appeal of having certain choices open to people in the reproductive realm, especially for issues like abortion rights. However, this liberal reading of reproductive autonomy only offers us a limited ethical understanding of what is at stake in many kinds of reproductive choices, particularly when it comes to different uses of reproductive technologies and third-party reproduction. This is because the liberal framework does not fully capture who benefits from which reproductive options, the extent of the risks and harms involved in various reproductive interventions, and the reasons for why people are driven to make certain reproductive choices.
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Affiliation(s)
- J Y Lee
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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8
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Asagumo A. Relational Autonomy, the Right to Reject Treatment, and Advance Directives in Japan. Asian Bioeth Rev 2022; 14:57-69. [PMID: 34917187 DOI: 10.1007/s41649-021-00191-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 11/23/2022] Open
Abstract
Although the patient’s right to decide what they want for themselves, which is encompassed in the notion of ‘patient-centred medicine’ and ‘informed consent’, is widely recognised and emphasised in Japan, there remain grave problems when it comes to respecting the wishes of the no-longer-competent when death is imminent. In general, it is believed that the concepts above do not include the right to refuse treatment when treatment withdrawal inevitably results in death, even when the patient previously expressed the wish to exercise this right when competent. In this paper, I first explain the current social and legal situation in Japan, where the lack of legal clarity regarding the right to reject treatment tends to result in doctors adopting the interpretation of patients’ words that is least conducive to treatment withdrawal. I then argue that the right to refuse treatment should be taken seriously, even when the patient is no longer competent, or the treatment refusal will result in death. I suggest that the concept of relational autonomy might have some practical and valuable implications in a country where individual autonomy is considered incompatible with societal values. Finally, I answer possible objections to relational autonomy and address the widespread societal concern about sliding down the slippery slope from allowing the right to refuse treatment to the obligation to die.
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9
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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.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35/3, 3000 Louvain, Belgium
| | - Rafael Amo Usanos
- Bioethics Chair at the Universidad Pontificia Comillas, C/Universidad Comillas, 3, 28049 Madrid, Spain
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Fonner VA, Ntogwisangu J, Hamidu I, Joseph J, Fields J, Evans E, Kilewo J, Bailey C, Goldsamt L, Fisher CB, O'Reilly KR, Ruta T, Mbwambo J, Sweat MD. "We are in this together:" dyadic-level influence and decision-making among HIV serodiscordant couples in Tanzania receiving access to PrEP. BMC Public Health 2021; 21:720. [PMID: 33853559 PMCID: PMC8045366 DOI: 10.1186/s12889-021-10707-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A substantial number of new HIV infections in sub-Saharan Africa occur within stable couples. Biomedical prevention (pre-exposure prophylaxis, PrEP) and treatment (antiretroviral therapy, ART) can provide benefits to sexual partners and can be used to prevent infection within HIV serodiscordant couples. However, research is typically focused on individuals, not dyads, even when the intervention may directly or indirectly impact sexual partners. Gaps remain in understanding best practices for recruitment, informed consent, and intervention implementation in studies involving HIV prevention and treatment among heterosexual serodiscordant couples. This qualitative study was undertaken to understand and describe decision-making and dyadic-level influence among members of serodiscordant couples regarding (1) participation in a dyadic-based research study involving HIV self-testing and access to PrEP, and (2) utilization of PrEP and ART. METHODS This qualitative study was nested within an observational cohort study assessing the acceptability of home-based couples' HIV self-testing and uptake of dyadic care for serodiscordant couples involving facilitated referral for HIV-positive partners and access to PrEP for HIV-negative partners. Semi-structured in-depth interviews were conducted among a subset of study participants (n = 22) as well as individuals involved in serodiscordant relationships who chose not to participate (n = 9). Interviews focused on couples' decision-making regarding study participation and dyadic-level influence on medication use. Interviews were transcribed verbatim and translated from Kiswahili into English. Data were analyzed using thematic analysis. RESULTS Three major themes were identified: (1) HIV as "two people's secret" and the elevated role of partner support in serodiscordant relationships; (2) the intersectional role of HIV-status and gender on decision-making; (3) the relational benefits of PrEP, including psychosocial benefits for the couple that extend beyond prevention. CONCLUSIONS The study found that couples made joint decisions regarding study participation and uptake of HIV-related medication. Relational autonomy and dyadic-level influence should be considered within research and programs involving HIV serodiscordant couples.
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Affiliation(s)
- Virginia A Fonner
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA.
| | - Jacob Ntogwisangu
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Isihaka Hamidu
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juliet Joseph
- Medical University of South Carolina, College of Medicine, Charleston, SC, USA
| | - Joshua Fields
- Medical University of South Carolina, College of Medicine, Charleston, SC, USA
| | - Evans Evans
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jordan Kilewo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claire Bailey
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA
| | - Lloyd Goldsamt
- New York University, Rory Meyers College of Nursing, New York, NY, USA
| | - Celia B Fisher
- Fordham University, Department of Psychology and Center for Ethics Education, Bronx, NY, USA
| | - Kevin R O'Reilly
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA
| | - Theonest Ruta
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jessie Mbwambo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Michael D Sweat
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA
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11
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Menon S, Entwistle VA, Campbell AV, van Delden JJM. Some Unresolved Ethical Challenges in Healthcare Decision-Making: Navigating Family Involvement. Asian Bioeth Rev 2021; 12:27-36. [PMID: 33717329 PMCID: PMC7747266 DOI: 10.1007/s41649-020-00111-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 11/05/2022] Open
Abstract
Family involvement in healthcare decision-making for competent patients occurs to varying degrees in many communities around the world. There are different attitudes about who should make treatment decisions, how and why. Legal and professional ethics codes in most jurisdictions reflect and support the idea that competent patients should be enabled to make their own treatment decisions, even if others, including their healthcare professionals, disagree with them. This way of thinking contrasts with some cultural norms that put more emphasis on the family as a decision-making entity, in some circumstances to the exclusion of a competent patient. Possible tensions may arise between various combinations of patient, family members and healthcare professionals, and healthcare professionals must tread a careful path in navigating family involvement in the decision-making process. These tensions may be about differences of opinion about which treatment option is best and/or on who should have a say or influence in the decision-making process. While some relevant cultural, legal and policy considerations vary from community to community, there are ethical issues that healthcare professionals need to grapple with in balancing the laws and professional codes on decision-making and the ethical principle of respecting patients and their autonomy. This paper will highlight and propose that a partial resolution to these issues may lie in relational understandings of autonomy, which in principle justify interventions by healthcare professionals and family that support patients in decision-making.
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Affiliation(s)
- Sumytra Menon
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vikki A Entwistle
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alastair V Campbell
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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12
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Stoljar N. Disgust or Dignity? The Moral Basis of Harm Reduction. Health Care Anal 2020; 28:343-351. [PMID: 33098488 DOI: 10.1007/s10728-020-00412-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/01/2022]
Abstract
Harm reduction has been advocated to address a diverse range of public health concerns. The moral justification of harm reduction is usually presumed to be consequentialist because the goal of harm reduction is to reduce the harmful health consequences of risky behaviors, such as substance use. Harm reduction is contrasted with an abstinence model whose goal is to eradicate or reduce the prevalence of such behaviors. The abstinence model is often thought to be justified by 'deontological' considerations: it is claimed that many risky behaviors are morally unacceptable, and therefore that we have a moral obligation to recommend abstinence. Because harm reduction is associated with a consequentialist justification and the abstinence model is associated with a deontological justification, the potential for a deontological justification of harm reduction has been overlooked. This paper addresses this gap. It argues that the moral duty to protect autonomy and dignity that has been advocated in other areas of medical ethics also justifies the public health policy of harm reduction. It offers two examples-the provision of supervised injection sites and the Housing First policy to address homelessness-to illustrate the argument.
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Affiliation(s)
- Natalie Stoljar
- Department of Philosophy and Institute for Health and Social Policy, McGill University, 855 Sherbrooke St, W., Montreal, QC, H3A 2T7, Canada.
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13
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Gómez-Vírseda C, de Maeseneer Y, Gastmans C. Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities. BMC Med Ethics 2020; 21:50. [PMID: 32605569 PMCID: PMC7325052 DOI: 10.1186/s12910-020-00495-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/23/2020] [Indexed: 12/24/2022] Open
Abstract
Background Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized. Main body Here, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis. Conclusion This article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35/3, 3000, Leuven, Belgium.
| | - Yves de Maeseneer
- Faculty of Theology and Religious Studies (Theological and Comparative Ethics), KU Leuven, Sint-Michielsstraat 4 - box 3101, B-3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 blok d - box 7001, 3000, Leuven, Belgium
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14
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Abstract
Background Preconception Expanded Carrier Screening (ECS) is a genetic test offered to a general population or to couples who have no known risk of recessive and X-linked genetic diseases and are interested in becoming parents. A test may screen for carrier status of several autosomal recessive diseases at one go. Such a program has been piloted in the Netherlands and may become a reality in more European countries in the future. The ethical rationale for such tests is that they enhance reproductive autonomy. The dominant conception of autonomy is individual-based. However, at the clinic, people deciding on preconception ECS will be counselled together and are expected to make a joint decision, as a couple. The aim of the present study was to develop an understanding of autonomous decisions made by couples in the context of reproductive technologies in general and of preconception ECS in particular. Further, to shed light on what occurs in reproductive clinics and suggest concrete implications for healthcare professionals. Main text Based on the shift in emphasis from individual autonomy to relational autonomy, a notion of couple autonomy was suggested and some features of this concept were outlined. First, that both partners are individually autonomous and that the decision is reached through a communicative process. In this process each partner should feel free to express his or her concerns and preferences, so no one partner dominates the discussion. Further, there should be adequate time for the couple to negotiate possible differences and conclude that the decision is right for them. The final decision should be reached through consensus of both partners without coercion, manipulation or miscommunication. Through concrete examples, the suggested notion of couple autonomy was applied to diverse clinical situations. Conclusions A notion of couple autonomy can be fruitful for healthcare professionals by structuring their attention to and support of a couple who is required to make an autonomous joint decision concerning preconception ECS. A normative implication for healthcare staff is to allow the necessary time for decision-making and to promote a dialogue that can increase the power of the weaker part in a relationship.
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Affiliation(s)
- Amal Matar
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Box 564, 751 22, Uppsala, Sweden
| | - Anna T Höglund
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Box 564, 751 22, Uppsala, Sweden.
| | - Pär Segerdahl
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Box 564, 751 22, Uppsala, Sweden
| | - Ulrik Kihlbom
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Box 564, 751 22, Uppsala, Sweden
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15
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Carrieri D, Peccatori FA, Grassi L, Boniolo G. Dealing with death in cancer care: should the oncologist be an amicus mortis? Support Care Cancer 2020; 28:2753-9. [PMID: 31712952 DOI: 10.1007/s00520-019-05137-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/16/2019] [Indexed: 10/25/2022]
Abstract
The way death is (not) dealt with is one of the main determinants of the current crisis of cancer care. The tendency to avoid discussions about terminal prognoses and to create unrealistic expectations of fighting death is seriously harming patients, families and healthcare professionals, and the delivery of high-quality and equitable care. Drawing on different literature sources, we explore key dimensions of the taboo of death: medical, policy, cultural. We suggest that the oncologist, from a certain moment, could take on the role of amicus mortis, a classical figure in the past times, and thus accompanying patients towards the end of their life through palliation and linking them to psychosocial and ethical/existential resources. This presupposes the implementation of Supportive Care in Cancer and the ethical idea of relational autonomy based on understanding patients' needs considering their sociocultural contexts. It is also key to encourage public conversations beyond the area of medicine to re-integrate death into life.
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16
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Abstract
In this article I discuss the little examined relationship between time and patient autonomy. Using the findings from a study on the experience of premenopausal cancer patients making fertility preservation decisions during their treatment, I focus on how the patients in the study understood time, and how this understanding interacted with and influenced their decision-making. I then analyse in more depth the importance of time in patient decision-making, and the relationship of time to concepts of patient autonomy and decision-making in the field of bioethics more generally. Focusing on the relational conception of autonomy, I conclude that time is an integral part of patient autonomy which warrants further research, such that it can be better integrated into concepts of patient autonomy, and the policy and guidelines that they inform and influence.
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Affiliation(s)
- Alexis Paton
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, George Davies Building, Leicester, LE1 7RH, UK.
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17
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Gómez-Vírseda C, de Maeseneer Y, Gastmans C. 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 2019; 20:76. [PMID: 31655573 DOI: 10.1186/s12910-019-0417-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Respect 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. METHODS Using 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. RESULTS Fifty 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. CONCLUSIONS Three 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.
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18
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Abstract
PURPOSE OF REVIEW Genomic tests offer increased opportunity for diagnosis, but their outputs are often uncertain and complex; results may need to be revised and/or may not be relevant until some future time. We discuss the challenges that this presents for consent and autonomy. RECENT FINDINGS Popular discourse around genomic testing tends to be strongly deterministic and optimistic, yet many findings from genomic tests are uncertain or unclear. Clinical conversations need to anticipate and potentially challenge unrealistic expectations of what a genomic test can deliver in order to enhance autonomy and ensure that consent to genomic testing is valid. SUMMARY We conclude that 'fully informed' consent is often not possible in the context of genomic testing, but that an open-ended approach is appropriate. We consider that such broad consent can only work if located within systems or organisations that are trustworthy and that have measures in place to ensure that such open-ended agreements are not abused. We suggest that a relational concept of autonomy has benefits in encouraging focus on the networks and relationships that allow decision making to flourish.
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Affiliation(s)
- Rachel Horton
- Clinical Ethics and Law at Southampton (CELS), Faculty of Medicine, University of Southampton, Centre for Cancer Immunology, Southampton General Hospital, Southampton, SO16 6YD UK
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, SO16 5YA UK
| | - Anneke Lucassen
- Clinical Ethics and Law at Southampton (CELS), Faculty of Medicine, University of Southampton, Centre for Cancer Immunology, Southampton General Hospital, Southampton, SO16 6YD UK
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, SO16 5YA UK
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19
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Shih P, Rapport F, Hogden A, Bierbaum M, Hsu J, Boyages J, Braithwaite J. Relational autonomy in breast diseases care: a qualitative study of contextual and social conditions of patients' capacity for decision-making. BMC Health Serv Res 2018; 18:818. [PMID: 30359251 PMCID: PMC6202865 DOI: 10.1186/s12913-018-3622-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 10/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A relational approach to autonomy refers to the way in which social conditions and relationships shape a person's self-identity and capacity in decision-making. This article provides an empirical account of how treatment choices for women undergoing breast diseases care are fostered within the dynamics of their relationships with clinicians, family members, and other aspects of their social environment. METHODS This qualitative study recruited ten women undergoing treatment at a breast programme, and eight clinicians supporting their care, in a private teaching hospital in New South Wales, Australia. Fourteen patient-clinician consultation observations and 17 semi-structured interviews were conducted. Schema analysis of interview transcripts were undertaken by a team of researchers and corroborated by observational fieldnotes. RESULTS Relational identities of patients influenced the rationale for treatment decision-making. Patients drew on supportive resources from family and medical advice from clinicians to progress with treatment goals. While clinicians held much social power over patients as the medical experts, patients highlighted the need for clinicians to earn their trust through demonstrated professionalism. Information exchange created a communicative space for clinicians and patients to negotiate shared values, promoting greater patient ownership of treatment decisions. As treatment progressed, patients' personal experiences of illness and treatment became a source of self-reflection, with a transformative impact on self-confidence and assertiveness. CONCLUSION Patients' confidence and self-trust can be fostered by opportunities for communicative engagement and self-reflection over the course of treatment in breast disease, and better integration of their self-identity and social values in treatment decisions.
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Affiliation(s)
- Patti Shih
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
| | - Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
| | - Anne Hogden
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
| | - Mia Bierbaum
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
| | - Jeremy Hsu
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
| | - John Boyages
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Health and Medical Sciences, Macquarie University, Sydney, NSW Australia
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20
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Abstract
Ageism within the context of care has attracted increasing attention in recent years. Similarly, autonomy has developed into a prominent concept within health care law and ethics. This paper explores the way that ageism, understood as a set of negative attitudes about old age or older people, may impact on an older person's ability to make maximally autonomous decisions within health care. In particular, by appealing to feminist constructions of autonomy as relational, I will argue that the key to establishing this link is the concept of self-relations such as self-trust, self-worth and self-esteem. This paper aims to demonstrate how these may be impacted by the internalisation of negative attitudes associated with old age and care. In light of this, any legal or policy response must be sensitive to and flexible enough to deal with the way in which ageism impacts autonomy.
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Affiliation(s)
- Laura Pritchard-Jones
- CSEP, School of Law, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
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21
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Ruhe KM, De Clercq E, Wangmo T, Elger BS. Relational Capacity: Broadening the Notion of Decision-Making Capacity in Paediatric Healthcare. J Bioeth Inq 2016; 13:515-524. [PMID: 27365104 DOI: 10.1007/s11673-016-9735-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 04/28/2016] [Indexed: 06/06/2023]
Abstract
Problems arise when applying the current procedural conceptualization of decision-making capacity to paediatric healthcare: Its emphasis on content-neutrality and rational cognition as well as its implicit assumption that capacity is an ability that resides within a person jeopardizes children's position in decision-making. The purpose of the paper is to challenge this dominant account of capacity and provide an alternative for how capacity should be understood in paediatric care. First, the influence of developmental psychologist Jean Piaget upon the notion of capacity is discussed, followed by an examination of Vygostky's contextualist view on children's development, which emphasizes social interactions and learning for decision-making capacity. In drawing parallels between autonomy and capacity, substantive approaches to relational autonomy are presented that underline the importance of the content of a decision. The authors then provide a relational reconceptualization of capacity that leads the focus away from the individual to include important social others such as parents and physicians. Within this new approach, the outcome of adults' decision-making processes is accepted as a guiding factor for a good decision for the child. If the child makes a choice that is not approved by adults, the new conceptualization emphasizes mutual exchange and engagement by both parties.
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Affiliation(s)
- Katharina M Ruhe
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
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22
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Spruit SL, van de Poel I, Doorn N. Informed Consent in Asymmetrical Relationships: an Investigation into Relational Factors that Influence Room for Reflection. Nanoethics 2016; 10:123-138. [PMID: 27478516 PMCID: PMC4949294 DOI: 10.1007/s11569-016-0262-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 04/21/2016] [Indexed: 06/06/2023]
Abstract
In recent years, informed consent has been suggested as a way to deal with risks posed by engineered nanomaterials. We argue that while we can learn from experiences with informed consent in treatment and research contexts, we should be aware that informed consent traditionally pertains to certain features of the relationships between doctors and patients and researchers and research participants, rather than those between producers and consumers and employers and employees, which are more prominent in the case of engineered nanomaterials. To better understand these differences, we identify three major relational factors that influence whether valid informed consent is obtainable, namely dependency, personal proximity, and existence of shared interests. We show that each type of relationship offers different opportunities for reflection and therefore poses distinct challenges for obtaining valid informed consent. Our analysis offers a systematic understanding of the possibilities for attaining informed consent in the context of nanomaterial risks and makes clear that measures or regulations to improve the obtainment of informed consent should be attuned to the specific interpersonal relations to which it is supposed to apply.
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Affiliation(s)
- Shannon Lydia Spruit
- Department of Values, Technology and Innovation, Delft University of Technology, Delft, The Netherlands
| | - Ibo van de Poel
- Department of Values, Technology and Innovation, Delft University of Technology, Delft, The Netherlands
| | - Neelke Doorn
- Department of Values, Technology and Innovation, Delft University of Technology, Delft, The Netherlands
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23
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Metze RN, Kwekkeboom RH, Abma TA. The potential of Family Group Conferencing for the resilience and relational autonomy of older adults. J Aging Stud 2015; 34:68-81. [PMID: 26162727 DOI: 10.1016/j.jaging.2015.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022]
Abstract
Family Group Conferencing (FGC) is emerging in the field of elderly care, as a method to enhance the resilience and relational autonomy of older persons. In this article, we want to explore the appropriateness of these two concepts to understand the FGC process in older adults. Using a case study design, we researched eight FGC cases for older adults, and selected two cases for further analysis and comparison. We found that the concepts of relational autonomy and resilience provide insight in the FGC process. Compassionately interfering social contacts, showing respect for the older person's needs and wishes gave older adults an impulse to take action to solve their problems. The capacity of a person to initiate and maintain social relations, and his or her willingness to ask for help, seemed essential to foster behavioral change. But apart from these, other, contextual factors seem to be important, which are currently not included in the theoretical framework for FGC, such as the nature of the problems, the involvement and capacities of the social network, and the older person's background.
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Affiliation(s)
- Rosalie N Metze
- Amsterdam University of Applied Social Sciences, Amsterdam Research Center for Societal Innovation, Wibautstraat 5a, 1091 GH Amsterdam, The Netherlands.
| | - Rick H Kwekkeboom
- Amsterdam University of Applied Social Sciences, Amsterdam Research Center for Societal Innovation, Wibautstraat 5a, 1091 GH Amsterdam, The Netherlands.
| | - Tineke A Abma
- Dept. of Medical Humanities, VU University Medical Centre and EMGO+ Research Institute, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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24
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Abstract
Within law and legal scholarship there are different models of legal personality and legal capacity. The most well known of these emphasises individual rationality, and is distilled into the medico-legal concept of 'mental capacity'. In connection with the UN Convention on the Rights of Persons with Disabilities (CRPD) a new approach to legal personality is being developed, emphasising relationships of support and recognition of universal legal capacity. Recent scholarship on both 'mental capacity' and CRPD approaches to legal capacity has drawn from feminist writings on relational autonomy. In this paper, I use this scholarship on relational autonomy to explore the differences between these approaches to legal capacity. I argue that the approach connected with the CRPD offers a refreshing take on the importance of relationships of support in exercising legal capacity. However, despite their pronounced differences, especially in relation to the legitimacy of coercion, there are remarkable similarities in the underlying challenges for each approach: the extent to which others can 'know' our authentic and autonomous selves, and the inextricable relationships of power that all forms of legal capacity are embedded within.
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Affiliation(s)
- Lucy Series
- School of Law and Politics, Cardiff University, United Kingdom.
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25
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Wade K. Refusal of emergency caesarean section in Ireland: a relational approach. Med Law Rev 2013; 22:1-25. [PMID: 24255134 DOI: 10.1093/medlaw/fwt021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This article examines the issue of emergency caesarean section refusal. This raises complex legal and ethical issues surrounding autonomy, capacity, and the right to refuse treatment. In Ireland, the situation is complicated further by the constitutional right to life of the unborn. While cases involving caesarean section refusal have occurred in other jurisdictions, a case of this nature has yet to be reported in Ireland. This article examines possible ways in which the interaction of a woman's right to refuse treatment and the right to life of the unborn could be approached in Ireland in the context of caesarean section refusal. The central argument of the article is that the liberal individualistic approach to autonomy evident in the caesarean section cases in England and Wales is difficult to apply in the Irish context, due to the conflicting constitutional rights of the woman and foetus. Thus, alternative visions of autonomy which take the interests and rights of others into account in medical decision-making are examined. In particular, this article focuses on the concept of relational consent, as developed by Alasdair Maclean and examines how such an approach could be applied in the context of caesarean section refusal in Ireland. The article explains why this approach is particularly appropriate and identifies mechanisms through which such a theory of consent could be applied. It is argued that this approach enhances a woman's right to autonomy, while at the same time allows the right to life of the unborn to be defended.
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Affiliation(s)
- Katherine Wade
- Department of Children and Youth Affairs Research Scholar, Faculty of Law, University College Cork, Ireland
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