Relational Autonomy, Paternalism, and Maternalism

Abstract

The concept of paternalism is intricately tied to the concept of autonomy. It is commonly assumed that when paternalistic interventions are wrong, they are wrong because they impede individuals’ autonomy. Our aim in this paper is to show that the recent shift towards conceiving of autonomy relationally highlights a separate conceptual space for a nonpaternalistic kind of interpersonal intervention termed maternalism. We argue that maternalism makes a twofold contribution to the debate over the ethics of interpersonal action and decision-making. Descriptively, it captures common experiences that, while not unusual in everyday life, are largely absent from the present discussion. Normatively, it describes a type of intervention with justification conditions distinct from the standard framework of paternalism. We explicate these contributions by describing six key differences between maternalism and paternalism, and conclude by anticipating and responding to potential objections.

This is a preview of subscription content, log in to check access.

Notes

  1. 1.

    There are two main forms of paternalism, state paternalism and interpersonal paternalism. There has been much work recently relating to both kinds. In this paper, we focus on interpersonal interferences, leaving open the question of whether our arguments in later sections extend into state interference or not.

  2. 2.

    In recent work, John Christman has begun the task of bringing together theories of paternalism with theories of relational autonomy. Although we share in the general thrust of Christman’s work, our analysis differs in its aim. Whereas Christman has used relational autonomy to question standards of antipaternalism, our goal is to harness these same relational resources to describe a non-paternalistic intervention.

  3. 3.

    This is also a separate project from Sara Ruddick’s “Maternal Thinking” (1980; 1989), which describes the discipline or thought processes of mothers. The projects are similar in that both are interested in a kind of caring labor, but dissimilar in that Ruddick describes maternal thinking as the particular practice of mothering, while we identify maternalism as a general ethical concept.

  4. 4.

    Paternalistic interventions need not be so simple, and recent work has described a rich variety of possible paternalisms (Begon 2016). These paternalisms step away from this classic version in many ways, as we discuss further in Section 5.

  5. 5.

    Some have argued that the wrongness of paternalism is found not in autonomy-violation, but in the uniquely insulting paternalist motive (Shiffrin 2000; Quong 2011). Such views identify paternalist acts as those motivated by a negative judgment about the person’s ability to make decisions that promote her interests (Quong 2011: 80). This view has held some sway, but recently has been criticized on a number of grounds – many of which seek to show that it is not, in fact, distinct from the autonomy-based view of the wrongness of paternalism. For example, Chris Mills (2013) has objected that Quong’s argument is successful only when it relies on the strength of its rival view, the argument from personal autonomy. Peter De Marneffe (2006) has called into question whether the paternalist motive is unique, or need be insulting, in the ways specified by the motivational view; this is especially the case, he argues, in light of empirical findings questioning our abilities to choose in line with our welfare and interests. Also, David Enoch has argued that the wrong of paternalism lies not in having a negative judgment or belief, but in the decision to act on this judgment: we have exclusionary reasons, based on personal autonomy, not to act on such judgments (2016: 26–30). Here, we accept a broad autonomy-based view without committing ourselves to any particular account.

  6. 6.

    We can distinguish between autonomous choices, autonomous actions, and autonomous agency (Holroyd 2009). An autonomous choice is a mental act (dependent on an agent’s mental capacities and content, such as beliefs), while an autonomous action is the execution of a choice (dependent on an agent’s governance of her body and the physical possibility of carrying out specific actions). Autonomous agency, by contrast, refers to the agent’s capacities, as developed and exercised over the course of his or her life – also referred to as autonomy competencies (Meyers 1989). Such agential competencies are a precondition for autonomous choices and acts. Our concern here is with autonomous agency, unless otherwise specified.

  7. 7.

    Relational autonomy is not alone in this observation, and in this sense it is closely tied to the ethics of care. Building on the work of Carol Gilligan, Marian Verkerk has described how using care ethics as a lens on ethical theory leads to a critique of traditional conceptions of autonomy as premised on an ideal of independence. In the place of the free and independent autonomous self, a care ethical lens focuses less on self-sufficiency, the wrong of interference, and individual rights and more on reciprocity, the wrong of abandonment, and relational responsibility (Gilligan 1986; Verkerk 2001: 291). Thus, while our comments here are primarily offered using the language of relational autonomy, they should be understood as of a piece within the broader approach of an ethics of care (Little 1998).

  8. 8.

    The other is Holroyd 2009.

  9. 9.

    Marian Verkerk also describes a form of intervention which she terms “compassionate interference,” in which medical professionals (she cites psychiatric professionals in particular) form caring relationships with their patients to help them to regain their self-respect and self-esteem after oppressive and damaging social experiences (Verkerk 2001: 293). This means, in some cases, proactively inquiring about the patients’ activities and feelings and directing the patient to act in certain ways based on this knowledge. Likewise, Laura Specker Sullivan has proposed that Japanese professionals’ nondisclosures of cancer diagnoses directly to certain patients are mischaracterized as paternalistic, a conceptual designation that misrepresents the purposes, methods, and relationships that form the context for these interventions (Specker Specker Sullivan 2016).

  10. 10.

    These comparisons focus on classic paternalism, which is defined as an intervention that violates an individual’s autonomy or fails to take it into account in some important way. As we discuss in section 5, some new versions of paternalism will be more similar to maternalism across some of these comparisons, and these comparisons are not meant to draw stark borderlines between the two conceptual frameworks. However, as we argue in section 5, there is a conceptual difference between paternalism and maternalism’s approaches to autonomy, one which John Christman describes as the difference between respecting autonomy (through non-interference) and valuing autonomy (through supportive interaction) (Christman 2014: 373; also see Mackenzie 2008).

  11. 11.

    While a full analysis of Talbert’s four contextual features warrants a paper in its own right (e.g., what is it to know another person without bias, or without deception?), we agree with her general description of what it means to know another person.

  12. 12.

    This is not necessarily the case for all forms of paternalism. Soft paternalistic interventions, for example, are aimed at confirming the voluntariness or rationality of the individual’s will. We discuss this point in more detail in section 5.

  13. 13.

    Kim Atkins has further described how intimate others can gain access to the subjective character of an individual’s experience (Atkins 2000).

  14. 14.

    This does not mean that M should be willing to make a decision for SM just because it is something that SM wills or wants. Rather, the decision must be in line with SM’s will and in her best interests, on M’s understanding of these. (An interesting question arises in cases where SM’s will and her best interests come apart. Should M refrain from acting in order not to paternalize? While this is not an issue we can resolve here, we propose it is just one of the interesting questions raised by maternalism.)

  15. 15.

    This is clearly seen within the institutional context, where it is questionable whether P – a choice architect (on Sunstein’s account of noncoercive means paternalism) or another state actor (on Conly’s coercive version) – can know SP’s relevant pro-attitudes beyond probabilistic judgments based on, e.g., demographics. This means that means paternalism will often collapse into ends paternalism, absent any further empirical grounding for its claim about supporting SP’s own ends (Rebonato 2012: 195–196; Mills 2017).

References

  1. Akabayashi A, Fetters MD, Elwyn TS (1999) Family consent, communication, and advance directives for cancer disclosure: a Japanese case and discussion. J Med Ethics 25:296–301

    Article  Google Scholar 

  2. Atkins K (2000) Autonomy and the subjective character of experience. J Appl Philos 17(1):71–79

    Article  Google Scholar 

  3. Baier A (1986) Trust and antitrust. Ethics 96(2):231–260

    Article  Google Scholar 

  4. Begon J (2016) Recent work: paternalism. Analysis 76(3):355–373

    Article  Google Scholar 

  5. Charles C, Gafni A, Whelan T (1991) Decision-making in the physician-patient encounter: revisiting the shared treatment decision model. Soc Sci Med 49:651–661

    Article  Google Scholar 

  6. Christman J (2004) Relational autonomy, liberal individualism and the social constitution of selves. Philos Stud 117:143–164

    Article  Google Scholar 

  7. Christman J (2014) Relational autonomy and the social dynamics of paternalism. Ethical Theory Moral Pract 17:369–382

    Article  Google Scholar 

  8. Christman J, Anderson J (2005) Introduction. In: Christman J, Anderson J (eds) Autonomy and the challenges of liberalism: new essays. Cambridge University Press, Cambridge, pp 1–23

  9. Conly S (2013) Against autonomy: justifying coercive paternalism. Cambridge University Press, Cambridge

    Google Scholar 

  10. Dalmiya V (2016) Caring to know: comparative care ethics, feminist epistemology, and the Mahabharata. Oxford University Press, New Delhi

    Google Scholar 

  11. De Marneffe P (2006) Avoiding paternalism. Philos Public Aff 34:68–94

    Article  Google Scholar 

  12. Dworkin G (1988) The theory and practice of autonomy. Cambridge Univeristy Press, New York.

  13. Enoch D (2016) What’s wrong with paternalism: autonomy, belief and action. Proc Aristot Soc 116(1):21–48

    Article  Google Scholar 

  14. Feinberg J (1986) Harm to self. Oxford University Press, Oxford

    Google Scholar 

  15. Friedman M (2003) Autonomy, gender, politics. Oxford University Press, Oxford

    Google Scholar 

  16. Gaylin W, Jennings B (2003) The perversion of autonomy: coercion and constraint in a liberal society. Revised and expanded edition. Georgetown University Press, New York

  17. Gilligan C (1986) Remapping the moral domain: new images of self in relationship. In: Heller T, Sosna M, Wellbery D (eds) Reconstructing individualism: autonomy, individuality, and the self in western thought. Stanford University Press, Stanford, pp 237–252

    Google Scholar 

  18. Harding S (2004) Rethinking standpoint epistemology: what is ‘strong objectivity’?'. In: Alcoff L, Potter E (eds) Feminist epistemologies. Routledge, New York, pp 49-82

  19. Holroyd J (2009) Relational autonomy and paternalistic interventions. Res Publica 15:321–336

    Article  Google Scholar 

  20. Horn, Elizabeth (2015) Maternalism in medicine. Huffington Post Healthy Living January 30, 2015

  21. Justin R (1985) Maternalism: A sound concept in medicine. Indiana Med 78(2):111–112

  22. Katz J (1984) The silent world of doctor and patient. Johns Hopkins University Press, Baltimore, MD

    Google Scholar 

  23. Le Grand J, New B (2015) Government paternalism: nanny state or helpful friend? Princeton University Press, Princeton

    Google Scholar 

  24. Lindemann Nelson H, Lindemann Nelson J (1995) The patient in the family. Routledge Reflective Bioethics Series

  25. Little MO (1998) Care: From Theory to Orientation and Back. J Med Philos 23(2):190–209

    Article  Google Scholar 

  26. Mackenzie C (2008) Relational autonomy, normative authority, and perfectionism. J Soc Philos 39(4):512–533

    Article  Google Scholar 

  27. Mackenzie C, Stoljar N (eds) (2000) Relational autonomy: feminist perspectives on autonomy, agency, and the social self. Oxford University Press, Oxford

    Google Scholar 

  28. Meyers D (1989) Self, society and personal choice. Columbia University Press, New York

    Google Scholar 

  29. Mill JS (2005) On liberty. Cosimo, New York

    Google Scholar 

  30. Mills C (2013) The problem of paternal motives. Utilitas 25(4):446–462

    Article  Google Scholar 

  31. Mills, Chris (2017), The choice architect’s trilemma. Res Publica (published online first on 9th August 2017. https://doi.org/10.1007/s11158-017-9363-4)

    Article  Google Scholar 

  32. Niker F, Specker Sullivan L (2018) Trusting relationships and the ethics of interpersonal actions. Int J Philos Stud 26(2)

    Article  Google Scholar 

  33. Noddings, Nel (2010) The maternal factor: two paths to morality. University of California Press, Los Angeles

  34. Petrillo, Laura (2014) A call for maternalism in medicine. Geripal: a geriatrics and palliative care blog. October 10, 2014

  35. Quong J (2011) Liberalism without perfection. Oxford University Press, Oxford

    Google Scholar 

  36. Rebonato R (2012) Taking liberties: a critical examination of libertarian paternalism. Palgrave Macmillan, London

    Google Scholar 

  37. Ruddick S (1980) Maternal thinking. Fem Stud 6(2):342–367

    Article  Google Scholar 

  38. Ruddick S (1989) Maternal Thinking. Beacon Press, Boston

  39. Schneider C (1998) The practice of autonomy: patients, doctors, and medical decisions. Oxford University Press, New York

    Google Scholar 

  40. Shiffrin S (2000) Paternalism, unconscionability doctrine, and accommodation. Philos Public Aff 29(3):205–250

    Article  Google Scholar 

  41. Skocpol T (1995) Protecting soldiers and mothers: the political origins of social policy in the United States. Harvard University Press, Cambridge

  42. Specker Sullivan L (2016) Medical maternalism: beyond paternalism and antipaternalism. J Med Ethics 42(7):439–444

    Article  Google Scholar 

  43. Specker Sullivan L, Niker F (2017) Relational autonomy, maternalism, and the nocebo effect. Am J Bioeth 17(6):52–54

    Article  Google Scholar 

  44. Stoljar N (2011) Informed consent and relational conceptions of autonomy. J Med Philos 36(4):375–384

    Article  Google Scholar 

  45. Sunstein C (2014) Why nudge? The politics of libertarian paternalism. Yale University Press, London

    Google Scholar 

  46. Talbert BM (2015) Knowing other people: a second person framework. Ratio 28:190–206

    Article  Google Scholar 

  47. Tronto J (1993) Moral boundaries: a political argument for an ethics of care. Routledge, New York

    Google Scholar 

  48. Tsai G (2016) The virtue of being supportive. Pacific Philosophical Quarterly

  49. Verkerk M (2001) The care perspective and autonomy. Med Health Care Philos 4(3):289–294

    Article  Google Scholar 

  50. Wilson-Barnett J (1986) Ethical dilemmas in nursing. J Med Ethics 12(123–126):135

    Google Scholar 

Download references

Acknowledgments

We would like to thank Kimberley Brownlee, Lily Lamboy, and Adam Swift, as well as audiences at Stanford’s Political Theory workshop and at the College of Charleston’s Department of Philosophy, for helpful comments on earlier versions of this paper.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Laura Specker Sullivan.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Specker Sullivan, L., Niker, F. Relational Autonomy, Paternalism, and Maternalism. Ethic Theory Moral Prac 21, 649–667 (2018). https://doi.org/10.1007/s10677-018-9900-z

Download citation

Keywords

  • Autonomy
  • Relational autonomy
  • Paternalism
  • Maternalism
  • Care ethics