When Relational Theory Is Absent from Qualitative Health Research: A Commentary on "Relational Autonomy as a Theoretical Lens for Qualitative Health Research" by Jennifer A. H. Bell

1. Introduction

In "Relational Autonomy as Theoretical Lens for Qualitative Bioethics Research" Jennifer A. H. Bell (2020) shows the importance of attending to the relational factors that affect the autonomy of research participants. Drawing on the example of her own research into cancer clinical trial participation, Bell illustrates how relational autonomy theory enhances the various stages of qualitative research. Relational theory can contribute insight into the development of a research question. It can help determine research methodology, and it can provide direction on the data sources needed for the study. As recommended by relational theory, the informed consent process should take oppression and power imbalances into account. Relational autonomy theory can also fruitfully influence data analysis—the derivation of meaning from the data. As Bell states about her own research project, "my goal was a comprehensive understanding of the multiple and overlapping personal and sociopolitical influences on patients' relational autonomy and decision-making processes within the cancer clinical trial context" (78). Without the guidance of a theory like relational autonomy that is highly sensitive to the effects of sociopolitical power and disadvantage on the capacities of patients, the operation of these influences may not be detected by the researcher.

As Bell shows, access to clinical trials for cancer may not be the same for everyone. Access can be affected by class, race, or language. Furthermore, clinical trial access, or lack thereof, can have ramifying effects on the health of patients and on research results. Bell notes that the clinical interventions we develop arise from the research we conduct. We can end up with interventions that support autonomy or those that do not. In order to avoid adding to the oppression of disadvantaged groups, and in order to uphold the autonomous capacities of patients and research participants, we must pay close attention to the factors that affect autonomy, from the beginning of the research project to the end.

Bell's research is a positive example of the use of relational theory in qualitative health research. Here I would like to tell a cautionary tale about the failure to place the lens of relational theory on health research and the ethical dangers that arise from this failure. Bell's insights can be appreciated more deeply by showing the problems associated with neglecting relational autonomy.

2. A study in which relational theory is absent

One study, by Thierry Pelaccia and his colleagues (2016), concerns clinical decision-making by emergency physicians. It is entitled "From Context Comes Expertise: How Do Expert Emergency Physicians Use Their Know-Who to Make Decisions?" and it was published in the Annals of Emergency Medicine. The article describes an innovative method. Physicians participating in the study wore a micro-camera fixed on their heads or on their glasses, at eye level, that recorded interactions with patients from the physician's perspective. The patients were admitted to the emergency department in one of three hospitals located in either Canada or France. After the micro-camera recorded the clinical encounter, a researcher interviewed the physician as they watched the clinical encounter together, stopping the recording from moment to moment so that the researcher could ask the physician to make explicit his or her reasoning and thought-processes at that moment in time.

Pelaccia et al.'s (2016) main finding is that emergency physicians use "their knowledge of other health care professionals to assess the seriousness of the patient's overall condition (sometimes even before his or her arrival in the ED [emergency department]) to optimize the patient's treatment and to anticipate future care" (747). This means that physicians rely on information about patients provided by others in the care team, such as triage nurses and paramedics, in their assessment of the patient. Emergency physicians also believe the information or discount it, depending on their beliefs about the credibility of the source, based on past experience. For example, the study quotes a physician saying he did not take a certain nurse to be a reliable source of information...