“Spinoza, Relational Autonomy, and Shared Decision-Making” presentation
This month, I am please to share the audio-visual presentation I gave to the Chair of Canadian Research on Shared Decision-Making. You can find the transcript below.
Transcript
In today's presentation, I aim to share some ways in which Spinoza's theory of autonomy can contribute to ongoing debates about the implementation of SDM.
Specifically, I will argue that Spinoza's version of relational autonomy proposes to work within existing power asymmetries by focusing on personalised and practical affective management that encourage and support the patient's relational "power of acting".
This will lead me to propose a broad, systemic view of SDM that goes beyond the sphere of the patient-doctor dyad and requires institutional uptake.
Given the expertise of my audience today, I decided that it would be more useful if I led up to discussing Spinoza. As a result, I will be spending much more time on point 3, but would be happy to expand on points 1 and 2 in the question period.
I will begin by explaining what problem a philosophical approach to SDM can address, namely the theory-practice gap, by identifying autonomy as a key SDM concept.
Then, I will briefly mention the ongoing contributions of feminist philosophy to the redefinition of autonomy as a relational capacity as these theories inform my interpretation of Spinoza and my interest in para-rational affectivity.
Finally, I will explain what I mean by Spinoza's theory of power and how it can help us reframe the quest for autonomy within asymmetrical relationships, like the ones between patients and medical practitioners.
This is a quote from the National Health Service Scotland's report to the Scottish government in 2018:
"Although many examples of excellent practice exist across NHS Scotland, effective shared decision-making between clinicians and patients is not yet universally embedded. The current challenge is to devise effective ways for supporting cultural transformation, engaging the public and embedding best practice within mainstream clinical processes."
This quote summarises the frustration often expressed in medical journals, sociology of medicine literature, and patient accounts. It also reflects my own decades-long experience as a disabled patient: most people agree that SDM is a good idea, but it is still unclear how one is supposed to practice it.
In this presentation, I argue that "devising effective ways for supporting cultural transformation" is best done when attending to para-rational affects, the factors and causes that help people act rationally. This point of view where rational capacity is considered in relation with a person's whole bodymind and its history is the point of view of relational autonomy.
I would like to present three axis of analysis: the kind of autonomy at play, the desired outcome of SDM, and the role of MPs in relation to patient autonomy.
As a philosopher, I saw an opportunity to examine the definition of SDM and its underlying theoretical assumptions in order to propose ways of bridging this theory-practice gap. My research eventually led me to focus on autonomy and I concluded that, even though SDM is a more deliberative model of doctor-patient interaction (compared to, e.g. informed consent models), it will be difficult to apply as long as it rests on the notion of autonomy linked to the use of independent or "pure" reason. As a result, by asking what kind of autonomy we are dealing with I am pointing out that individualistic or rights-based models of autonomy are not the only ones and I argue that they need to be replaced or complemented in order for SDM to become part of healthcare culture.
Reflecting on what kind of autonomy is at the heart of SDM policies also leads us to define what the desired outcome of SDM is. This may seem like a straightforward question, but it is not. There are many reasons that motivate the adoption of SDM and they often overlap (with more or less friction): better resource management and other economic reasons, ideals of democracy and equality, political pressures, improved health outcomes, legal concerns.
These questions lead me to propose that the role of a healthcare provider is embedded in a much larger system of norms and relations that encourage and repress autonomy and that biomedical knowledge alone does not grant epistemic superiority nor is it equivalent to rational capacity. Therefore, any attempt to balance the power dynamic between patients and clinicians need to take into account the embedded and relational quality of knowledge production on both sides of the equation. This means accepting that the autonomous and rational thing to do sometimes means overriding biomedical preferences.
Briefly, RA is a feminist theory of autonomy that posits that there is no such thing as an independent subject and that autonomy, like all human capacities, is developed in relation with one's environment. Heralded by philosophers like Catriona Mackenzie and Natalie Stoljar, RA has been securing some uptake in bioethics, thanks in part to the efforts of Susan Sherwin.
RA has importantly framed autonomy as a capacity that can be developed or oppressed by social norms and institutions and Mackenzie in particular has raised the need to expand our understanding of rationality in regards to autonomy to include emotional or affective factors.
By "affect" I understand the physical and mental manifestation of a change in the power to act. Some affects can accompany rational and autonomous acts (e.g. joy that comes from understanding) and others diminish one's capacity to understand and, therefore, one's autonomy (e.g. fear or hatred). Importantly, our affective nature conditions how we process knowledge and it is necessary to understand it in order to tackle the barriers to empowering autonomy.
I choose to introduce Spinoza's philosophy to the conversation about a move away from "respect for autonomy" towards empowerment because Spinoza makes a theoretical choice to focus on growing existing power rather than supplementing perceived deficits.
The notion of respect does not involve a dynamic quality whilst empowerment demands some kind of supportive activity. Once we recognize that our psycho-social, material and political environments shape what we call the agent we can start to differentiate between supportive and oppressive relations, thereby giving us criteria by which we can measure our environment-shaping efforts moving forward.
The 3 Spinozist themes I want to focus on today are as following: embodied rationality, relational power, and autonomy as a practice.
To explain this move from respect to empowerment I need to spend some time explaining Spinoza's definition of reason. Reason for Spinoza is a tool, a way of ordering our ideas according to their causes. In this sense, general knowledge of properties must be informed by the particulars of a situation in order to qualify as "rational". In other words, what is rational for one person (i.e. what empowers them to act according to their nature) is not the same for someone else.
This kind of empowerment is not the expression of a fixed or static degree of autonomy: it is developed in relation. Crucially for Spinoza, however, empowering relations must pay attention to what he calls "affects", or the bodymind's changes towards more or less power (I borrow the compounded term "bodymind" from crip theory because Spinoza maintains that there is no dualistic body-mind separation). Some affects like joy and self-esteem increase one's power of acting and others, like sadness and hatred, diminish it. This fluctuation can never be entirely controlled by the individual and depends on their environment and web of relations.
This leads me to frame Spinoza's theory of autonomy as a practice, as a collective effort of empowerment that is dynamic, non-linear, and ongoing. A practice is not a possession, nor is it a right. It evolves, involves personal effort, must be resilient to changing circumstances, and can be supported and encouraged by external factors. To shift towards autonomy as a practice while taking into account a relational understanding of embodied rationality is to reframe the conditions of autonomy.
The individualistic model of autonomy that underlies many health care policies tends to treat emotions with suspicion because they are wary of manipulation. While Spinoza recognises the unstable and sometimes harmful role of affects, he does maintain that, as we can never escape embodiment, we must identify and encourage para-rational affects.
In the clinical setting, this will affect communicative and deliberative practices. Not only are the patient's affects relevant to their receiving biomedical information, but the affects of the practitioner come into play as well. Since Spinoza focuses on practical reason, decision-making is about figuring out together what is the "good" in that particular relationship and this requires that each party adapts to the other. This means that clinicians engaging in SDM must also pay attention to their own affects and act towards collective empowerment by contributing to a supportive environment. This includes accepting that their biomedical point of view is not necessarily the most important factor in every health-related case. For example, I have been in many consultation rooms with doctors who did not know how to treat my symptoms. Faced with this limit to their knowledge, many reacted by dismissing my claims or minimizing them, thereby making a stressful situation worse and damaging my relationship with the healthcare system. I needed to be believed more than I needed a prescription in those cases. McManimen + Horn
Another thing embodied rationality in Spinoza highlights is that each relation is embedded in a web of other relations. Therefore, SDM processes are determined by a patient's relationship to healthcare systems in general as well as to a particular practitioner. This has important implications when it comes to trust: clinicians should never assume that they, as professionals within a system, have or deserve the patient's trust. Without tending to these affective realities, SDM is improbable.
A Spinozist relational approach to autonomy has one major implication: that everyone has a base-level of agency. This means that, when approaching someone to engage them in a decision-making process, we must attend to the ways that agency has been shaped, consider the form of our own agency at that moment, and try to connect in such a way that increases the autonomy of all involved.
In a concrete way, this means paying attention to the changes in degrees of autonomy, which includes affective factors as well as the communication of true information. In the end, the patient-doctor relationship is inscribed in a much larger web of autonomy-encouraging and autonomy-repressing relations.
This, in turn, means that practitioners ought to reflect on their own degree of autonomy as it fluctuates and their relation to other stakeholders. If increasing patient autonomy is the goal of SDM, we have to accept that there are multiple ways of evaluating the success of the process, including contributing to patient autonomy beyond the relationship with one practitioner. For example, if repairing lost trust or addressing medical harm is the only thing a SDM process can do, that would count as a success in a Spinozist sense.
Ultimately, adopting a scalar notion of relational autonomy means committing to the agency that is before us and within us at that moment. It means recognizing that values and ideas we take for granted (like "health" or what is someone's "best interest") must be re-examined time and time again as we engage in SDM with different people and even over time with the same person. This practice is done on multiple levels using a variety of different approaches.
At the heart of the SDM theory-practice gap is the reality of asymmetrical power relations: the average person seeking medical care is inherently in a vulnerable position vis-à-vis someone with greater material, political, and epistemic power. Efforts to promote patient autonomy in this context must be atuned to the embodied nature of rationality and Spinoza's philosophy encourages us to continually place ourselves and our immediate relations within a much broader scope. In this sense, medical practitioners take part in a diversified approach to shape individual autonomy and, therefore, SDM in healthcare should attend to the importance of empowering affects and the systems that facilitate them.
In conclusion, a Spinozist approach to SDM reframes the decision-making process as one that aims to empower patients by working with their existing agency and helping them develop it. "Power" here means the "power of acting" which depends on individual understanding within an affective environment that can either facilitate or repress this power of acting. Others, like Thomas et al in the Journal of Evaluation in Clinical practice, are making use of philosophical concepts to attend to epistemic injustice. My argument works in tandem with theirs, joining them in calling for SDM that is situated within broader systemic and social practices, centering autonomous empowerment beyond the patient-doctor dyad. Spinoza's philosophy brings a different emphasis that urges us to pay attention to affectivity in relation to autonomy.
Merci beaucoup. Je peux maintenant répondre à vos questions.