Essays in the Philosophy of Humanism 24.1 (2016) 1–20 ISSN 1522-7340 (print) ISSN 2052-8388 (online) doi:10.1558/eph.31406 Toward an Account of Relational Autonomy in Healthcare and Treatment Settings Simone Lee Joannou Witwatersrand University [email protected] Abstract Currently held conceptions of autonomy that inform biomedicine are inade- quate and oppressive. Liberal notions of individualism are anti-humanist and constitute pernicious socialization, which leads to internalized oppression and dehumanization, especially among already oppressed groups. Women in recovery from addiction and other mental illnesses are especially affected by anti-humanist conceptions of autonomy. I argue that these women need to receive treatment that supports autonomy through supplementing psychiat- ric and rehabilitative therapy with humanistic education and group therapy. Treatment must encourage the construction of healthy social interaction that augments a sense of supported autonomy. Keywords autonomy, mental health, relational autonomy, feminist conceptions of autonomy, recovery, therapeutic ethics The following essay serves to discuss the inadequacy and ensuing oppression of currently held conceptions of autonomy that inform biomedical concep- tions of autonomy. I make specific reference to treatment for women with addiction and other mental illnesses, and that only a substantive, relational account of autonomy will adequately support the autonomy of those recover- ing from these maladies. Traditional liberal conceptions of autonomy to be not only inadequate in addressing the causal factors involved in the develop- ment of addiction and mental illness, but to be an underlying cause itself. I argue that the liberal notion of “every man for himself” constitutes perni- cious socialization and, in turn, internalized oppression and dehumanization. This notion forces, explicitly or implicitly, members of oppressed groups to feel isolated and guilty for feeling overly dependent, and thus unable to ask © Equinox Publishing Ltd. 2016, Office 415, The Workstation, 15 Paternoster Row, Sheffield, S1 2BX 2 Relational Autonomy in Healthcare Settings for help. The feeling that one is losing control of one’s life is compounded by the experience of isolation. Further, the implicit power dynamics in the physician-patient relationship can also undermine autonomy. Thus, women in recovery from addiction and other mental illnesses need to receive treat- ment that supports autonomy. This can be achieved by supplementing psy- chiatric and rehabilitation therapy with humanistic education and group therapy. Women must understand the layers of pernicious socialization that leave them vulnerable to addiction and other mental illnesses, and treatment should more than encourage the construction of healthy social interaction to augment a sense of supported autonomy. Through the process of understand- ing and connection, women may be able to successfully recover and become autonomous. I begin by critiquing the current biomedical conception of autonomy as heavily influenced by the liberal tradition. An adequate account of auton- omy must account for dehumanizing, oppressive forces, including pernicious socialization and internalized oppression. These forces undermine an agent’s sense of self-worth and self-trust, which undermine autonomy. I argue for a substantive account of autonomy which takes self-worth and self-trust as necessary conditions for autonomy. Further, with reference to Carolyn Ells’ analysis of autonomy in people with disabilities, I demonstrate that healthy relationships augment an agent’s autonomy, while toxic relationships serve to significantly undermine it. With reference to Jennifer Nedelsky’s re-con- ception of autonomy, I find further support in the idea that participation in one’s social environment tends to increase the experience of autonomy. McLeod and Sherwin’s discussion of the necessity of self-trust in an adequate theory of autonomy provides an appropriate springboard into my concerns about agents’ experiences of reduced autonomy in mental-healthcare settings. As they argue, physicians are responsible for providing their patients with relevant and adequate information, as well as opportunities to participate in decisions regarding treatment. The same should be applied in mental-health- care settings. A sense of participation within a healthy social context that fos- ters a sense of self-worth is a tonic for social ills that no medication can cure. This is foundational for humanism both within and outside of the clinic. Critique of the traditional, liberal conception of autonomy which informs current biomedical models of autonomy According to Nedelsky and most feminist and communitarian philosophers, liberalism takes “atomistic individuals to be the basic unit of political and legal thought” (1989, 8). This conception leads individuals to view the collec- tive as a threat to autonomy, and encourages individuals to build boundaries and walls to protect their autonomy, which they view as something privately © Equinox Publishing Ltd. 2016 Simone Lee Joannou 3 owned in the same way an individual owns property. According to this the- ory, “the most perfectly autonomous man is the one who is most perfectly isolated” (12). Essentially this model teaches that autonomy gives the indi- vidual power to shut out others, providing the individual with power from and over other people, rather than power over their own lives. Ells points out that the liberal theory that informs current biomedical models of autonomy takes individuals to be free, equal, rational and self- contained choosers. She stresses that the individualist theory proffered by lib- eralism places great emphasis on independence and self-sufficiency. McLeod and Sherwin characterize traditional autonomy theory as one that focuses on impediments to autonomy, and would rather concern itself with evaluating an individual’s ability to act autonomously in any given situation. Like Ells, these writers recognize that the traditional theory of autonomy understands autonomy as an achievement or reward for individuals. Here there is a sense in which, akin to the neoliberal model of homo economicus, an individual works for and earns autonomy. They have paid for it, so to speak, and they are thus entitled to protect it from perceived threats. This conception of autonomy fails in several ways to capture the essence of an autonomous human person. It fails to recognize that the individual is inherently a social being, that social living is indeed constitutive of per- sonhood. I agree with Nedelsky when she poignantly refers to the problem of self-determination as pathological; a sickness of society. She goes on to explain that the dichotomy between individuality and collectivity proffered by liberalism is an illusory one. The dichotomy reinforces the idea that the collective poses a threat to personal autonomy and this distorts our percep- tions of our place in social contexts. This false belief in separation serves to cut individuals from all sorts of social arrangements that could indeed sup- port autonomy. I understand her to mean that the notion of self-sufficiency that is embedded in the liberal theory tends to give connection with others and interdependence a bad name, thus discouraging connection with others. What Nedelsky takes as the foundation of traditional autonomy theory is the idea that autonomy is akin to personal property. The liberal conception suggests that autonomy should be private and protected from external forces, but she ardently refuses to accept that this model works. This theory encour- ages individuals to surround themselves with boundaries for the sake of autonomy, yet these boundaries produce harmful results that actually dimin- ish autonomy. Nedelsky discusses how an agent’s sense of participation in the collective augments the experience of autonomy. Pertinently, she stresses that the experience of autonomy is essential, distinguishing it from the traditional view of autonomy as an achievement. Overall, Nedelsky urges us to adopt an account of autonomy that moves beyond that which considers human beings © Equinox Publishing Ltd. 2016 4 Relational Autonomy in Healthcare Settings as separate individuals, and one that views community not as a threat but a foundation for autonomy. In Ells’ analysis of the experience of autonomy in people with disabili- ties, she insists that we acknowledge that individuals are not self-contained choosers. Her analysis indicates that all individuals are interdependent and that autonomy is not something that is owned by an individual, but some- thing that is experienced by persons, all of whom are necessarily embodied and embedded in a social context. McLeod and Sherwin point out that the traditional theory, with its empha- sis on factors that impede autonomy, fails to recognize oppression as a factor which undermines autonomy. This is because traditional theories focus on threats to an individual’s autonomy, as opposed to the autonomy of groups of people. The prevalent theory of autonomy in biomedical ethics is heavily influenced by the traditional, liberal conception of autonomy, and is thus vulnerable to the same criticisms. The most widely recognized theory of autonomy in the biomedical community is attributed to Beauchamp and Childress. As paraphrased by Ells, they define autonomy as “personal rule of the self, being free from controlling interferences and free from personal limi- tations that prevent meaningful choice”