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Relational autonomy and the clinical relationship in dementia care

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Abstract

The clinical relationship (or doctor-patient relationship) has been underexplored in dementia care. This is in part due to the way that the clinical relationship has been articulated and understood in bioethics. Robert Veatch’s social contract model is representative of a standard view of the clinical relationship in bioethics. But dementia presents formidable challenges to the standard clinical relationship, including ambiguity about when the clinical relationship begins, how it weathers changes in narrative identity of patients with dementia, and how the intimate involvement of family fits alongside a paradigmatically dyadic relationship. Drawing on work in recent feminist theory, a critique is offered of the standard clinical relationship in bioethics as underwritten by an individualistic conception of autonomy. An alternative view of the clinical relationship in dementia, one that embraces a relational account of autonomy, is put forward.

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Notes

  1. Veatch initially called this the doctor-patient relationship, but like many others, he came to change his terminology to recognize the primacy of the patient within the relationship as well as different types of professionals who enter into relationships with patients. Ultimately, Veatch settles on the term “patient-provider relationship” [13].

  2. This monopolistic power has evolved since Veatch’s early formulation of the triple contract view but continues to be a feature of the medical profession in many societies.

  3. For Veatch, the point is not that the interests of the state always trump (after all, there may be deontological constraints, e.g., principles of veracity or confidentiality arising from the first level contract that put additional limits on the contract between society and the medical profession), but just that the duties of the physician fall out of, and are exhausted by, this contract and do not have an independent source in the clinical relationship itself [13].

  4. This is not dissimilar to psychiatric evaluations in which the determination of capacity is a catch 22. Though everyone has a right to refuse medical evaluation, so long as they have the capacity to do so, the only way to determine if this capacity is present is to conduct a capacity evaluation.

  5. It is worth noting that there are other examples that run against the dyadic paradigm, including care of children, adults with developmental disabilities, individuals with disorders of consciousness, and some kinds of psychiatric illness.

  6. This does not imply that just because dementia does not feature prominently in Veatch’s work that he did not take it to be important. One might credit Veatch with contributing to a movement in bioethics and medicine that improved the lives of many groups previously disempowered in medicine and society, including those with dementia. Though he talks little about dementia specifically, he does discuss cognitive disability [27].

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Acknowledgements

I wish to thank and remember Bob Veatch for his kindness, scholarship, and mentorship, and for his tireless commitment to the field he helped birth.

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  1. Department of Neurology, Oregon Health and Science University, Portland, OR, USA

    Eran Klein

  2. Center for Neurotechnology and Department of Philosophy, University of Washington, Seattle, WA, USA

    Eran Klein

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Correspondence to Eran Klein.

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Klein, E. Relational autonomy and the clinical relationship in dementia care. Theor Med Bioeth 43, 277–288 (2022). https://doi.org/10.1007/s11017-022-09580-5

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