Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model

K-FF and Y-PL are joint first authors.

Introduction

In end-of-life care, intricate decisions on whether to undergo invasive interventions or withhold or withdraw life-sustaining treatment involve not only great uncertainty but also tension between the patient’s self-determination and the interest of third parties. Respect for autonomy is widely asserted as a key arbiter, operationalised through assessing patients’ decision-making capacities and fulfilling their treatment preferences.¹ However, this principle’s role as an ideal ethical panacea is increasingly being challenged, particularly from the perspective of relational autonomy (RA).

Originally proposed in political and social philosophy, RA criticises the mainstream individualistic interpretation of autonomy for its omission of social connectedness as the quintessence of human existence and external forces on one’s autonomy.^2–4 RA has been increasingly adopted to resolve end-of-life issues,^5–9 and its proponents recognise that the clinician–patient relationship has important ramifications in fostering patient autonomy.¹⁰ Three ethical recommendations are commonly highlighted for clinicians: (1) merely securing patients’ informed consent is insufficient to respect their autonomy; (2) consulting or involving patients’ significant others in the decision-making process is desirable and; (3) one must sensitively deal with relevant historical, religious, cultural and social contexts that influence patient autonomy.

Despite these laudable recommendations, clinicians struggle with knotty dilemmas: how to ascertain the true beliefs of their patients, how to meaningfully engage with various parties,¹¹ and the potential disagreements among them.^{12 13} Further, given a patient who firmly endorses a rather unconventional cultural stance or personal conviction, should a dissenting clinician attempt to proactively change the patient’s perspective?¹⁴

Scholars generally endorse competence and authenticity as two essential conditions of autonomy, subject to specification by each theory.¹⁵ As a specific theory of autonomy, RA purports that individuals must possess some necessary competence apart from ordinary decision-making capacities and act according to their true desires or authentic selves.³ Some scholars propose an interdependent decision-making model that justifies different modes of involving others, depending on the patient’s capacity or competence.¹¹ However, this model fails to incorporate the patient’s authenticity and thus does not completely align with RA. Contrary to some early critics,^{16 17} authenticity has gained considerable traction in bioethical discourse.^18–21 Incorporating the authenticity condition of autonomy may produce a thorough,...