Postnatal reproductive autonomy: Promoting relational autonomy and self-trust in new parents

Bioethics

Volumn 23, Issue 1, 2009, Pages 9-19

  Goering, Sara ^a  

^a UNIVERSITY OF WASHINGTON   (United States)

Author keywords

Autonomy; Parent; Postnatal; Relational; Reproductive; Self trust

Indexed keywords

ATTITUDE TO HEALTH; DECISION MAKING; EDUCATION; ETHICS; HEALTH PROMOTION; HEALTH SERVICE; HUMAN; HUMAN RELATION; INFORMED CONSENT; METHODOLOGY; PARENT; PATIENT EDUCATION; PERSONAL AUTONOMY; PHYSICIAN ATTITUDE; POSTNATAL CARE; PSYCHOLOGICAL ASPECT; PSYCHOLOGICAL MODEL; REPRODUCTIVE RIGHTS; REVIEW; SELF CONCEPT; SOCIAL SUPPORT; TRUST;

ATTITUDE TO HEALTH; DECISION MAKING; HEALTH KNOWLEDGE, ATTITUDES, PRACTICE; HEALTH PROMOTION; HEALTH SERVICES NEEDS AND DEMAND; HUMANS; INFORMED CONSENT; INTERPERSONAL RELATIONS; MODELS, PSYCHOLOGICAL; PARENTS; PATIENT EDUCATION AS TOPIC; PERSONAL AUTONOMY; PHYSICIAN'S ROLE; POSTNATAL CARE; PROFESSIONAL-PATIENT RELATIONS; REPRODUCTIVE RIGHTS; SELF EFFICACY; SOCIAL SUPPORT; TRUST;

EID: 57649208028     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2008.00678.x     Document Type: Review

References (72)

1. To cite just a small sample: M. Warnock. 2002. Making Babies: Is There a Right to Have Children? New York: Oxford University Press;
2. L. Purdy. 1996. Reproducing Persons: Issues in Feminist Bioethics Ithaca, NY: Cornell University Press;
3. B. Katz-Rothmann. 1986. The Tentative Pregnancy: Prenatal Diagnosis and the Future of Motherhood. New York: Viking Press;
4. J. Harris & S. Holm (eds.). 2000. The Future of Human Reproduction: Ethics, Choice and Reproduction. New York: Oxford University Press;
5. C. Overall. 1994. Ethics and Human Reproduction: A Feminist Analysis. Boston: Allen and Unwin;
6. J. Robertson. 1996. Children of Choice: Freedom and the New Reproductive Technologies. Princeton: Princeton University Press;
7. M. Shanley. 2001. Making Babies, Making Families. Boston: Beacon Press;
8. U. Narayan & J. Bartkowiak (eds.). 1999. Having and Raising Children University Park, PA: Penn State University Press;
9. E. Parens & A. Asch, eds. 2000. Prenatal Testing and Disability Rights Washington DC: Georgetown University Press.
10. D. Davis. 2000.Genetic Dilemmas: Reproductive Technology, Parental Choice, and Children's Futures. New York: Routledge
11. J. Savulescu. Procreative Beneficence: Why We Should Select the Best Children. Bioethics 2001 15 : 413 426.
12. J. Lantos and W. Meadow. 2006. Neonatal Bioethics: The Moral Challenges of Medical Innovation. Baltimore: Johns Hopkins University Press;
13. R. Guyer. 2006. Babies at Risk: The Uncertain Legacies of Medical Miracles for Babies, Families, and Society. Herndon, VA: Capital Books.
14. Though we often conceive of autonomy as related only to decision making and perhaps the capacity to act on such decisions, I think a relational conception of autonomy, focused on social circumstances and their relation to individual skills and competencies, demonstrates how good care giving (of the self and for others) is linked to having autonomy. That is, an individual's ability to identify her values and to act on them may well depend on her level of social support provided by friends and other intimates who not only give her feedback and advice as she faces various decisions, but who also help her to define herself and to value her own judgment.
15. Conditions for being autonomous and exercising autonomy typically include such things as having authentic values (i.e., values that are sustained upon critical reflection) that are reflected in choices made free from undue external influence and in a mentally competent state.
16. K. Orfali. Parental Role in Medical Decision-Making: Fact or Fiction? Soc Sci Med 2004 58 : 2011.
17. D. Devictor. Parents' Autonomy versus Doctors' Paternalism: A Rearguard Battle. Pediatr Crit Care Med 2007 8 (4 400.
18. Orfali, Pediatr Crit Care, op.cit. note 6;
19. Lantos and Meadow, Pediatr Crit Care, op. cit. note 3.
20. Devictor, Pediatr Crit Care, op. cit. note 7.
21. R. Kukla. Conscientious Autonomy: Displacing Decisions in Health Care. Hastings Cent Rep 2005 35 (2 35.
22. S. Sherwin. 1998. A Relational Approach to Autonomy in Health Care. In The Politics of Women's Health: Exploring autonomy and agency. S. Sherwin, ed. Philadelphia, PA: Temple University Press: 20.
23. Kukla, The Politics of Women's Health: Exploring autonomy and agency, op. cit. note 10.
24. Kukla and Carolyn McLeod, whose work informs my understanding of the relationship between self-trust and autonomy, disagree in some respects in regard to when and under what conditions a woman might autonomously defer to the expertise of her care provider, though they both emphasize the importance of developing both trust in the physician and self-trust. The central point of contention is whether conscientious trust meets the same standard as McLeod's justified or appropriate trust. See their debate in the letters in the Hastings Cent Rep 35(5): 5-7.
25. K. Jones. 1999. Second-Hand Moral Knowledge. J Philos 96 (2 55 78.
26. For example, S. Sherwin, J Philos, op. cit. note 11;
27. C. McLeod. 2002. Self-Trust and Reproductive Autonomy. Boston: MIT Press;
28. D. Meyers. 1989. Self, Society and Personal Choice. New York: Columbia University Press;
29. C. Mackenzie & N. Stoljar, eds. 2000. Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self. New York: Oxford University Press.
30. C. Mackenzie & N. Stoljar. 2000. Introduction: Autonomy Refigured. In Relational Autonomy. New York: Oxford University Press: 3-31.
31. Sherwin, Relational Autonomy, op. cit. note 11, p. 36.
32. McLeod, Relational Autonomy, op. cit. note 15.
33. Meyers, Relational Autonomy, op. cit. note 15.
34. P. Benson. 2000. Feeling Crazy: Self-worth and the Social Character of Responsibility. In Relational Autonomy. New York: Oxford University Press: 72-93.
35. I don't want to take a substantive position here on exactly which skills constitute autonomy competency, nor do I want to defend either a procedural or a substantive view on autonomy - see Mackenzie & Stoljar, Relational Autonomy, op. cit. note 15. Rather, I want to show how the general tenor of these relational critiques of traditional autonomy might play out in the case of postnatal reproductive autonomy.
36. See H. Frankfurt. 1989. Freedom of the Will and the Concept of a Person. In The Inner Citadel: Essays on Individual Autonomy. J. Christman, ed. Oxford: Oxford University Press.
37. Benson, 2000. Of course if may also come in the form of how decision-making bodies are constituted, and how particular health care options are determined as suitable to be offered in the first place. For more discussion of the latter point, see Sherwin, The Inner Citadel: Essays on Individual Autonomy, op. cit. note 11.
38. McLeod, The Inner Citadel: Essays on Individual Autonomy, op. cit. note 15, p. 106.
39. A. Mullin. 2005. Reconceiving Pregnancy and Childcare: Ethics, Experience, and Reproductive Labor, Boston: Cambridge University Press;
40. K. Morgan. 1989. Of Woman Born? How Old-Fashioned! - New Reproductive Technologies and Women's Oppression. In Ethics and Human Reproduction. C. Overall, ed. Boston: Allen and Unwin.
41. See McLeod's story of Lee, who sought fertility services voluntarily and with great self-trust, but left 'feeling powerless and objectified, as if her identity had been threatened.' McLeod, Ethics and Human Reproduction, op. cit. note 15, p. 3. Even though the fertility expert did not directly coerce her into enduring the treatments, Lee's self-trust was undermined by her treatment in the clinic, and so she cannot be held to be fully autonomous.
42. McLeod, Ethics and Human Reproduction, op. cit. note 15.
43. McLeod, Ethics and Human Reproduction, op. cit. note 15, p. 147.
44. Annette Baier. Trust and Anti-Trust. Ethics 1986 96 (2 231 260.
45. Annette Baier. Trust and Anti-Trust. Ethics 1986; 96(2): 231-260. Ibid.
46. McLeod, Ethics, op. cit. note 15.
47. Amy Mullin. Trust, Social Norms, and Motherhood. J Soc Philos 2005 36 (3 316 330.
48. McLeod, J Soc Philos, op. cit. note 15.
49. McLeod, J Soc Philos, Ibid: chapters 2 and 3.
50. McLeod, J Soc Philos, Ibid.
51. McLeod, J Soc Philos, Ibid.
52. For an interesting discussion of the ways in which 'mothering' is not instinctive, see Mullin, J Soc Philos, op. cit. note 32, esp. chapter 5.
53. McLeod, J Soc Philos, op. cit. note 15.
54. Though as Eva Kittay argues, even if the decision to enter into parenthood may be voluntary, exit options are not. That is, as the primary caregivers of children, women's ability to leave a relationship may not be fully voluntary even though it is also uncoerced. E. Kittay. 1999. Love's Labor: Essays on Women, Equality and Dependency. New York: Routledge.
55. Here we can think not only of how a stereotype may be internalized by an oppressed person, but also how she might constrain her actions so that she will not be interpreted by others as living up to a common stereotype. See McLeod, Love's Labor: Essays on Women, Equality and Dependency, op. cit. note 15.
56. S. Dodds. 2000. Choice and Control in Feminist Bioethics. In Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self. C. Mackenzie & N. Stoljar, eds. New York: Oxford University Press: 230.
57. Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self, Ibid: 230.
58. Cultivating appropriate trust in the physician will serve to enhance parental autonomy in at least three ways: first, it shows the new parent that the physician is someone who can handle the discretionary power that is inevitably part of trust; second, when a trusting relationship is built, the parent's own self-trust is likely to benefit (through feedback provided in a constructive and supportive manner); and third, it allows the patient to, in some cases, accept a physician's advice 'conscientiously' (to use Kukla's term) even if she doesn't fully understand all the justifications behind it.
59. This three part division of recommendations is my own interpretation of McLeod's work on enhancing relational autonomy and self-trust in fertility services. McLeod, Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self, op. cit. note 15, chapter 7.
60. I recognize that a physician who aims to cultivate trust in her patients need not do so appropriately (that is, she might have questionable intentions and then mis-use the trust she has gained; this might be a problem even without explicit ill intentions if she thinks she deserves trust and then fails to recognize the problematic reasons that her patient may have for deferring to her authority). What matters here is cultivating appropriate trust rather than mere trust. Doing that, I would argue, involves both the physician and the patient being willing to question the basis of the trust and to articulate reasons for holding it. This is a complicated endeavor, though, as I do tend to agree with Baier when she notes that 'Trust is a fragile plant which may not endure inspection of its roots, even when they were, before the inspection, quite healthy.' Baier, Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self, op. cit. note 29, p. 260. For present purposes, perhaps it is enough to claim that appropriate trust will be more likely to arise under conditions in which multiple parties are able to provide a check on the trusting relationship. Other health team members, for instance, may serve to question appearances of inappropriate trust, and intimates of the new parents may likewise provide such an external perspective for them.
61. K. Young et al. 1998. Listening to Parents: A National Survey of Parents with Young Children. Arch Pediatr Adolesc Med 152 : 255 262
62. M. Schuster et al. 2000. Anticipatory Guidance: What Information Do Parents Receive? What Information Do They Want? Arch Pediatr Adolesc Med 154 : 1191 1198
63. N. Magar, S. Dabova-Missova D. Gjerdingen. 2006. Effectiveness of Targeted Anticipatory Guidance during Well-Child Visits: A Pilot Trial. J Am Board Fam Med 19 : 450 458.
64. J. Paris et al. 2006. Has the Emphasis on Autonomy Gone Too Far? Insights from Dostoevsky on Parental Decision-Making in the NICU. Camb Q Healthc Ethics 15 : 147 151.
65. I am reminded here of Kittay's discussion of doulia, or the idea of nested obligations such that society must provide social supports of care for primary caregivers, just as new mothers are sometimes provided doulas, who care for them as they care for their new babies. Kittay, Camb Q Healthc Ethics, op cit. note 39; see especially page 70. NICU teams need to support parents and to see them as patients of a sort, because they are intricately linked to the infant patient and her well-being.
66. Access to the internet's resources and images in such a situation is a mixed blessing.
67. R. Guyer. 2006. Baby at Risk: The Uncertain Legacies of Medical Miracles for Babies, Families, and Society. Herndon, VA: Capital Books, Inc: 126-127.
68. Guyer, 2006, p. 127.
69. This option is recommended by Schuster et al., Baby at Risk: The Uncertain Legacies of Medical Miracles for Babies, Families, and Society, op.cit. note 46, and over half the pediatricians surveyed in a study published in 2006 thought well-baby care might be provided in alternative locations such as day care centers.
70. T. Coker et al. 2006. Should Our Well-Child Care System Be Redesigned? A National Survey of Pediatricians. Pediatrics 118 (5 1852 1857.
71. McLeod, Pediatrics, op. cit. note 15, p. 77.
72. E. Cassell. 1999. Pain, Suffering, and the Goals of Medicine. In The Goals of Medicine M. Hanson and D. Callahan, eds. Washington DC: Georgetown University Press: 101-117.