Relational Capacity: Broadening the Notion of Decision-Making Capacity in Paediatric Healthcare
Problems arise when applying the current procedural conceptualization of decision-making capacity to paediatric healthcare: Its emphasis on content-neutrality and rational cognition as well as its implicit assumption that capacity is an ability that resides within a person jeopardizes children’s position in decision-making. The purpose of the paper is to challenge this dominant account of capacity and provide an alternative for how capacity should be understood in paediatric care. First, the influence of developmental psychologist Jean Piaget upon the notion of capacity is discussed, followed by an examination of Vygostky’s contextualist view on children’s development, which emphasizes social interactions and learning for decision-making capacity. In drawing parallels between autonomy and capacity, substantive approaches to relational autonomy are presented that underline the importance of the content of a decision. The authors then provide a relational reconceptualization of capacity that leads the focus away from the individual to include important social others such as parents and physicians. Within this new approach, the outcome of adults’ decision-making processes is accepted as a guiding factor for a good decision for the child. If the child makes a choice that is not approved by adults, the new conceptualization emphasizes mutual exchange and engagement by both parties.
KeywordsChildren Capacity Decision-making Relational autonomy Substantive
- ———. 2003. Die autonomie des kindes: Über die selbstbestimmungsfähigkeit von kindern in der medizin [Children’s autonomy: On children’s capacity to make decisions in healthcare]. In Das kind als patient—Ethische konflikte zwischen kindeswohl und kindeswille [Children as patients: Ethical conflicts between the child’s welfare and the child’s wishes], ed. C. Wiesemann, A. Dörries, G. Wolfslast, and A. Simon, 28–47. Frankfurt/Main: Campus Verlag.Google Scholar
- ———. 2007. Competent children? Minors’ consent to health care treatment and research. Social Science and Medicine 65(11): 2272–2283.Google Scholar
- Alderson, P., and J. Montgomery. 1996. Health care choices: Making decisions with children, Vol. 2. Institute for Public Policy Research.Google Scholar
- Beauchamp, T.L., and J.F. Childress. 2001. Principles of biomedical ethics. New York, NY: Oxford University Press.Google Scholar
- Buchanan, A.E., and D.W. Brock. 1989. Deciding for others: The ethics of surrogate decision making. Cambridge: Cambridge University Press.Google Scholar
- Bronfenbrenner, U. 1979. The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.Google Scholar
- Chaiklin, S. 2003. The zone of proximal development in Vygotsky’s analysis of learning and instruction. In Vygotsky’s educational theory in cultural context, ed. A. Kozulin, B. Gindis, V.S. Ageyev, and S.M. Miller. Cambridge: Cambridge University Press.Google Scholar
- Charland, L. 2011. Decision-making capacity. In Stanford Encyclopedia of Philosophy. http://seop.illc.uva.nl/entries/decision-capacity/. Accessed June 13, 2015.
- ———. 1998. Appreciation and emotion: Theoretical reflections on the MacArthur treatment competence study. Kennedy Institute of Ethics Journal 8(4): 359–376.Google Scholar
- Christman, J. 2003. Autonomy in moral and political philosophy. http://plato.stanford.edu/entries/autonomy-moral/. Accessed June 12, 2014.
- ———. 2004. Relational autonomy, liberal individualism, and the social constitution of selves. Philosophical Studies 117(1): 143–164.Google Scholar
- Gilligan, C. 1982. In a different voice: Harvard University Press.Google Scholar
- Held, V. 1993. Feminist morality: Transforming culture, society, and politics: University of Chicago Press.Google Scholar
- ———. 2007. Feminism and moral theory. Bioethics: An introduction to the history, methods, and practice: 158.Google Scholar
- Inhelder, B., H. Sinclair, and M. Bovet. 1974. Learning and the development of cognition. Translated by S. Wedgwood. Cambridge, MA, US: Harvard University Press.Google Scholar
- Mackenzie, C., and N. Stoljar. 2000. Relational autonomy: Feminist perspectives on automony, agency, and the social self. New York: Oxford University Press.Google Scholar
- Marti, E. 1996. Mechanisms of internalisation and externalization of knowledge in Piaget’s and Vygotsky’s theories. In Piaget - Vygostky, The social genesis of thought, ed. A. Tryphon and J. Vonèche. East Sussex: Psychology Press.Google Scholar
- Miller, P.H. 1993. Theorien der entwicklungspsychologie [Theories in Developmental Psychology]. Heidelberg: Spektrum Akademischer Verlag.Google Scholar
- Murray, F. 1983. Learning and development through social interaction and conflict: A challenge to social learning theory. Piaget and the foundations of knowledge: 231–247.Google Scholar
- Peter, C. 2008. Die Einwilligung von minderjährigen in medizinische eingriffe [Minors‘ consent in medical interventions]. Schweizerische Ärztezeitung 89(36): 1539–1540.Google Scholar
- Rogoff, B., C. Mosier, J. Mistry, and A. Göncü. 1993. Toddlers’ guided participation with their caregivers in cultural activity. In Contexts for learning: Sociocultural dynamics in children’s development, ed. E.A. Forman, N. Minick, and C.A. Stone, 175–179. New York: Oxford University Press.Google Scholar
- Ruhe, K.M., T. Wangmo, D.O. Badarau, B.S. Elger, and F. Niggli. 2014. Decision-making capacity of children and adolescents—Suggestions for advancing the concept’s implementation in pediatric healthcare. European Journal of Pediatrics 174(6): 1–8.Google Scholar
- Siegel, L.S., and B. Hodkin. 1982. The garden path to the understanding of cognitive development: Has Piaget led us into the poison ivy? In Jean Piaget: Consensus and controversy, ed. S. Modgil and C. Modgil, 239–245. London: Holt, Rinehart & Winston.Google Scholar
- Stoljar, N. 2013. Feminist perspectives on autonomy. Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/entries/feminism-autonomy/. Accessed December 6, 2014.
- Tryphon, A., and J. Vonèche. 2013. Piaget Vygotsky: The social genesis of thought. New York: Psychology Press.Google Scholar
- Vygotsky, L.S. 1978a. Interaction between learning and development. In Readings on the development of children, ed. M. Gauvain and M. Cole, 34–41. New York: W. H. Freeman and Company.Google Scholar
- ———. 1978b. Internalization of higher psychological functions. In Mind in society: The development of higher psychological processes, ed. M. Cole, V. John-Steiner, S. Scribner, and E. Souberman, 52–57. Cambridge, Massachussets: Harvard University Press.Google Scholar
- ———. 1986. Thought and language. Cambridge: The Massachusetts Institute of Technology.Google Scholar