Abstract
The current empowerment rhetoric that is discussed in digital health initiatives is problematic, Nickel et al. argue in a recent article that is published in this journal. They highlight social justice as a crucial value that should be re-engineered in this context. However, they do not take a stand on the relational meaning of autonomy. In this commentary, we instead claim that autonomy could better be conceptualized in relational terms as it brings into focus the importance of developing capabilities that can support self-determination. Such a conception of autonomy places greater emphasis on social justice concerns that mainstream bioethics tends to brush aside. Finally, we introduce the framework of Capability Sensitive Design as a better strategy to try to achieve empowerment through digital health.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data availability
Not applicable.
Notes
For instance, relational autonomy is also developed in Ubuntu ethics (Mhlambi & Tiribelli, 2023) or more Western-oriented ethical theories such as “care ethics, ethical multiculturalism, phenomenology, personalist ethics, relational ethics, virtue ethics, and different forms of political-philosophical approaches, such as communitarianism, liberalism, etc.” (Gómez-Vírseda et al., 2019, p. 12)
Most applications remain free despite billions in venture capital funding being secured every year for digital health applications. See Somaiya et al. (2023) for an overview of annual venture capital funding. While many in the development team may have the primary aim of developing a quality health product, investors are more likely to be concerned with profits. This focus on profits may incentivize the development of lower quality “general wellness products” that are designed to amass a large subscriber base, whose information is then used to market for-pay products and services to (Simon et al., 2022).
One such solution might come in the form of AI assistants that can assist a clinician in answering messages in online patient portals. ChatGPT, a non-medical AI assistant outperformed clinicians on metrics of both quality and empathy in responding to these message (Abbasi & Hswen, 2023). But it is not immediately obvious that this sort of solution will be utilized to help patients and broaden access. In some cases, clinicians can opt out of helping vulnerable patients (Krishnamurthy, 2023), and may instead use these AI assistants to reduce their own workloads as burnout and a shortfall of providers are pervasive throughout the healthcare industry.
References
Abbasi, J., & Hswen, Y. (2023). How AI assistants could help answer patients’ messages-and potentially improve their outcomes. JAMA. Advance online publication. https://doi.org/10.1001/jama.2023.22555.
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics. Oxford University Press.
Childress, J. F. (2017). Needed: A more rigorous analysis of models of decision making and a richer account of respect for autonomy. American Journal of Bioethics, 17(11), 52–54.
Childress, J. F. (2022). Respecting personal autonomy in bioethics: Relational autonomy as a corrective? In J. F. Childress & M. Quante (Eds.), Thick (concepts of) autonomy: Personal autonomy in ethics and bioethics (pp. 135–149). Springer.
Cortés-Albornoz, M. C., Ramírez-Guerrero, S., García-Guáqueta, D. P., Vélez-Van-Meerbeke, A., & Talero-Gutiérrez, C. (2023). Effects of remote learning during COVID-19 lockdown on children’s learning abilities and school performance: A systematic review. International Journal of Educational Development, 101, 102835.
De Proost, M., & Segers, S. (2023). Revisiting the ought implies can dictum in light of disruptive medical innovation. Journal of Medical Ethics. Advance online publication. https://doi.org/10.1136/jme-2023-108946.
Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. Oxford University Press.
Gómez-Vírseda, C., De Maeseneer, Y., & Gastmans, C. (2019). Relational autonomy: What does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Medical Ethics, 20(1), 76.
Ho, A. (2022). Artificial intelligence as a feminist bioethics issue. In W. A. Rogers, J. L. Scully, S. M. Carter, V. A. Entwistle, & C. Mills (Eds.), The Routledge handbook of feminist bioethics (pp. 291–307). Routledge.
Hopster, J., & Löhr, G. (2023). Conceptual engineering and philosophy of technology: Amelioration or adaptation? Philosophy and Technology, 36(4), 70.
Jacobs, N. (2020). Capability sensitive design for health and wellbeing technologies. Science and Engineering Ethics, 26(6), 3363–3391.
Jacobs, N., & Evers, J. (2023). Ethical perspectives on femtech: Moving from concerns to capability-sensitive designs. Bioethics, 37(5), 430–439.
Kapeller, A., & Loosman, I. (2023). Empowerment through health self-testing apps? Revisiting empowerment as a process. Medicine, Health Care and Philosophy, 26, 143–152.
Kreitmair, K. V. (2023). Mobile health technology and empowerment. Bioethics. Advance online publication. https://doi.org/10.1111/bioe.13157.
Krishnamurthy, K. B. (2023). Should physicians be able to refuse to care for patients insured by medicare? AMA Journal of Ethics, 25(12), 861–865.
Mackenzie, C. (2010). Conceptions of autonomy and conceptions of the body in bioethics. In J. L. Scully, L. Baldwin-Ragaven, & P. Fitzpatrick (Eds.), Feminist bioethics: At the center, on the margins (pp. 71–90). Baltimore: Johns Hopkins University Press.
Mackenzie, C. (2014). The importance of relational autonomy and capabilities for an ethics of vulnerability. In C. Mackenzie, W. Rogers, & S. Dodds (Eds.), Vulnerability: New essays in ethics and feminist philosophy (pp. 33–59). New York: Oxford University Press.
Mackenzie, C. (2019). Feminist innovation in philosophy: Relational autonomy and social justice. Women’s Studies International Forum, 72, 144–151.
Mackenzie, C., & Stoljar, N. (Eds.). (2000). Relational autonomy: Feminist perspectives on autonomy, agency, and the social self. Oxford: Oxford University Press.
Mhlambi, S., & Tiribelli, S. (2023). Decolonizing AI ethics: Relational autonomy as a means to counter AI harms. Topoi, 42, 867–880.
Morley, J., & Floridi, L. (2019). Enabling digital health companionship is better than empowerment. The Lancet Digital Health, 1(4), e155–e156.
Morley, J., & Floridi, L. (2020). The limits of empowerment: How to reframe the role of mHealth tools in the healthcare ecosystem. Science and Engineering Ethics, 26(3), 1159–1183.
Nickel, P. J., Loosman, I., Frank, L., & Vinnikova, A. (2023). Justice and empowerment through digital health: Ethical challenges and opportunities. Digital Society, 2(3), 42.
Quelly, S. B., Norris, A. E., & DiPietro, J. L. (2016). Impact of mobile apps to combat obesity in children and adolescents: A systematic literature review. Journal for Specialists in Pediatric Nursing, 21(1), 5–17.
Rawls, J. (1971). A theory of justice. Cambridge, MA: Harvard University Press.
Raz, J. (1986). The morality of freedom. Oxford: Clarendon Press.
Robeyns, I. (2006). The capability approach in practice. The Journal of Political Philosophy, 14(3), 351–376.
Saghai, Y. (2018). Theorizing justice in health research. In J. P. Kahn, A. C. Mastroianni, & J. Sugarman (Eds.), Beyond consent: Seeking justice in research (2nd ed., pp. 187–207). Oxford: Oxford University Press.
Sedhom, R., McShea, M. J., Cohen, A. B., Webster, J. A., & Mathews, S. C. (2021). Mobile app validation: A digital health scorecard approach. NPJ Digital Medicine, 4(1), 111.
Segers, S., & Mertes, H. (2022). The curious case of “trust” in the light of changing doctor–patient relationships. Bioethics, 36(8), 849–857.
Sen, A. (2008). The idea of justice. Journal of Human Development, 9(3), 331–342.
Sherwin, S. (1998). The politics of women’s health: Exploring agency and autonomy. Philadelphia: Temple University Press.
Simon, D. A., Shachar, C., & Cohen, I. G. (2022). Skating the line between general wellness products and regulated devices: Strategies and implications. Journal of Law and the Biosciences, 9(2), lsac015.
Somaiya, M., Shi, G., & Krasniansky, A. (2023). 2023 Q1 digital health funding: Investing like it’s 2019. Retrieved December 14, 2023, from https://rockhealth.com/insights/2023-q1-digital-health-funding-investing-like-its-2019/
Winters, N., Venkatapuram, S., Geniets, A., & Wynne-Bannister, E. (2020). Prioritarian principles for digital health in low resource settings. Journal of Medical Ethics, 46(4), 259–264.
Funding
This research has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No. 919841 – DIME).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing Interests
The authors declare no competing interests.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
De Proost, M., Gray, J. No Justice Without (Relational) Autonomy? Rethinking the Digital Empowerment Rhetoric. DISO 3, 8 (2024). https://doi.org/10.1007/s44206-024-00093-3
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s44206-024-00093-3