2. LITERATURE REVIEW
2.5 Feminist Alternatives to Principled Autonomy: Relational Models
2.5.2 Relational Autonomy in Context: Power and Relationship
empowerment and is more respectful and inclusive of the particularities of patients‟ lives and experiences (McGrath, 1998).
Moving beyond the narrow focus of informed consent in research contexts on conditions of adequate comprehension and competency to make voluntary choices is a central goal of Fisher‟s (2003) relational ethics. Fisher broadens the scope of informed consent in research to the
relationship between the researcher, the research participant and the consent context. This
involves not only recognizing how the broader social context affects individuals‟ decisions in the research setting, but also how researchers‟ own competencies and obligations are grounded within a particular context. From a relational perspective, informed consent becomes a product of mutual understanding and requires a shift from fulfilling conditions of autonomous choices to being responsive to the research participant‟s concerns, values and abilities. Obtaining consent then becomes an expression of connection and goodness-of-fit between researchers and their research participants (Fisher, 2003).
Accompanying the awareness that social relationships are necessary for the realization of autonomy, however, is acknowledgement that relationships can also impede or obstruct autonomy, or, as is the case for many women in non-Western cultures, eradicate autonomy altogether. The connection between autonomy and the social is a complex one, which can be positive and negative. Autonomy can be both enhanced and impeded by relationships. In
developing relational conceptions of autonomy, therefore, it is necessary to be cognizant of how social relationships can both promote and hinder the realization of autonomy (Friedman, 1997).
Nedelsky (1989) acknowledges the inexorable influence of relationships of power, of the collective, on individual autonomy and shows how this too often dichotomous tension between autonomy and collectivity can be reconciled in an alternative, more relational and more context- embedded conception of autonomy. Instead of viewing autonomy as a process of erecting walls between the individual and the threat of the collective, Nedelsky argues that relationships, not isolation, are necessary for the development and maintenance of autonomy – they constitute both the source of and danger to autonomy. “To be autonomous, a person must feel a sense of her own power (which does not mean power over others), and that feeling is only possible within a
structure of relationships conducive to autonomy” (Nedelsky, 1989, p. 25). Autonomy is an individual value which comes into being in the context of the social.
Others, too, have traced the theme of empowerment in relational conceptions of autonomy.
Fishbane (2001) considers how power imbalances do exist in society but shows how
reconceptualizing the nature of persons alters these narratives of power. Competitive values of power-over have traditionally been associated with notions of autonomy; changing the
underlying perspective to one of a relational view of persons challenges Western notions about power and the self.
While acknowledging and working to change these power differences and abuses of power, relational and feminist theorists are also challenging the power-over model with a power-to (Goodrich, 1991) or power-with or mutual empowerment (Surrey, 1991) model, especially in interpersonal relationships (Fishbane, 2001, p. 277).
This applies to men as well as women, argues Fishbane, in that the power-over model is socialized into our thinking about men‟s development – a dominant perception which can be altered by rethinking development in relational terms and reconsidering gender assumptions implicit in our culture.
Building on the recognition of the influence of power and relational inequalities on individuals‟
autonomy, Warren (2001) recommends an alternative conceptualization of autonomy that is based on notions of empowerment. While traditional autonomy is essentially individualistic, concepts of empowerment capture both the social and political context and reveal how power affects relationships and individual autonomy. An ethic of empowerment is, in many respects, better suited to realizing individual autonomy in research settings than are conventional
applications of informed consent. This is especially significant when research is conducted with vulnerable populations in developing countries like South Africa, where the operation and
influence of power relationships is clearly evident and unavoidable: both in the informed consent process, between researchers and research participants, and in the relationships between men and women in this society, where male power and control over females extends into many areas of their lives (Jobson, 2005; Memela, 2005; Sideris, 2004, 2005). Translating the discourse of empowerment into the ethical practice identifies and challenges these sources of power and inequality and finds ways of enhancing autonomy within these contexts (Warren, 2001).
Thus, while autonomy should not be abandoned, it is only part of the story, and needs to be modified to include (women‟s) “stories about how we are to live together, and how we are to make families and communities that support the growth of love, enduring loyalties and
compassion” (Murray, 1994, p. 33). The same argument applies to culture, and to the tendency to perceive one culture‟s worldview as superior to another. This is reflected in the domination of Western “independent” notions of self versus the interdependent views of personhood that are adopted in many non-Western cultures. In many developing countries, and in South Africa in
particular, there are cultures with differing worldviews from those of the First World values of independence from which individualistic conceptions of autonomy arise. Thus, while feminist voices can help us to focus on women‟s unique experiences of agency, feminist (bio)ethics can also facilitate the adoption of a critical perspective when attempting to mould principles of autonomy in informed consent practices into more gender- and culture-sensitive conceptions.
“The provisional goal here must be to acknowledge always the textuality of morality, and to encourage the self-determining individual to root herself in the moral community rather than abstract herself from it” (Shildrick, 1997, p. 123).
This section has provided a review of feminist models of relational autonomy. It has attempted to show how these models are a synthesis of the concepts explored in the preceding sections – integrating relational concepts of the self into traditionally individualistic principles of autonomy, and building on the integration of the predominant ethic of justice with an ethic of care that is based on these more connected notions of the self in relationship. What has become evident in these relational autonomy models is how the conventional principle of autonomy that was critiqued in previous sections can benefit from attending to the individualism inherent in Western bioethics and incorporating concepts from self-in-relation theories and care ethics that have previously been neglected in mainstream ethical approaches. The discussion above has demonstrated how these relational autonomy models can work in context by balancing out the power dynamics in the relationships that are inextricable from the research process, and
empowering those involved in the informed consent process by meeting them where they are in their lives. In the final section of this literature review, the models of relational autonomy that have been developed in this chapter will be further contextualized, showing how such relational
alternatives are more appropriate, more respectful, and, ipso facto, more ethical, for conducting research with women within their situated, real, lived circumstances and experiences.
2.6 Situating Relational Autonomy in Research Ethics in HIV Vaccine Trials in Developing