A Non-Paternalistic Conception of Relational Autonomy Still Needs Others

Halpern and Kim’s commentaries on our paper have highlighted several areas where we would like to clarify our position and bring into relief some of the unique features of our claims. In this response, we address Halpern’s arguments about thresholds for capacities and her concern that motivational interviewing (MI) is a disguised form of soft paternalism. We also address Kim’s interpretation of a relational self that does not require others’ participation. Their thoughtful engagement with our paper allows us to develop our position more fully and clearly.

Halpern notes that we use the term “capacities” in its plural form rather than the singular and interprets this to mean that we are rejecting the “existing distinction between having a threshold capacity and then exercising it or not” (Halpern 2013, 179). However, we do, in fact, recognize this distinction and use the plural form because we emphasize that an individual must meet a threshold capacity for three distinct capacities in order to be fully autonomous. These three capacities are self-determination, self-cohesion, and self-respect. There may be a different threshold for each capacity and individuals may significantly surpass the threshold for two capacities, but if they do not meet the threshold in the third, they would not be considered adequately autonomous. A multiple capacity model for autonomy acknowledges the complexity and relational nature of autonomy. Capacities can be promoted by the support that others provide or they can be undermined, intentionally or unintentionally. For those below or near the threshold for any of the three capacities, third parties are critical in their success or failure to achieve the capacities they need for autonomy. The relational nature of the threshold attainment of the capacities needed for autonomy is the foundation of the obligations for providers to actively promote and avoid undermining the capacities of their patients. Even patients who meet the minimum threshold for a capacity can still benefit from having that capacity supported by others.

We agree with Halpern’s distinction that although patients are evaluated to determine whether they meet the threshold for capacity to make decisions (a legal designation), they are not required to exercise this capacity and can, in fact, make the decision however they choose, including deferring the decision making to others, for example, to spouses or to their care providers. Providers trained in shared decision making and taught to avoid the appearance of paternalism often experience significant distress when patients defer their decision-making authority to their provider. However, many providers still have an inclination to look for justifications for overriding patients’ decisions when they significantly disagree with either the result or the process they seem to use to arrive at those decisions. Halpern highlights some of the moral dangers of allowing providers the right to determine if patients have properly exercised their capacity for decision making, which may grant providers too much leeway in deciding whether they should honor their patient’s decision. We agree with her. Competent adults should have their decisions honored even if providers believe that the patients have been overly influenced by irrational emotions, or they have deferred the decision to someone else.

Halpern is also concerned that our approach may promote soft paternalism. Halpern cites the example of offering small financial incentives to teenage moms to attend a support group to discourage future pregnancies. She characterizes this approach as ‘scaffolding autonomy’ which she cites as an example of soft paternalism. She is concerned that, like the incentivized support group example, MI may be working to not merely elicit people’s existing values, but to create a new value that the provider believes is a better or more “healthy” value. She argues that the providers are not “acting from the ethical responsibility to respect their patients’ autonomy,” but rather, from the “equally fundamental ethical responsibility” of promoting health and well-being (Halpern 2013, 179). We respectfully disagree. MI as it is often practiced (Resnicow and McMaster 2012) relies on a rigorous process of elicitation of...