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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.

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  1. 1.

    The example of Leila is not a real case but a fictional one which enables us to highlight those aspects that are relevant for the development of our argument. It is however inspired by real life cases of children refusing treatment (see for example Mercurio 2007; Cornock 2010).

  2. 2.

    In the United Kingdom, the concept of capacity carries legal connotations and competence clinical ones (Bielby 2013).

  3. 3.

    This contextualized and social decision-making process is not unique to childhood but is also beneficial in adult care. We thank the anonymous reviewer for highlighting this important aspect.


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Correspondence to Eva De Clercq.

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Ruhe, K.M., De Clercq, E., Wangmo, T. et al. Relational Capacity: Broadening the Notion of Decision-Making Capacity in Paediatric Healthcare. Bioethical Inquiry 13, 515–524 (2016).

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  • Children
  • Capacity
  • Decision-making
  • Relational autonomy
  • Substantive