Lydia Feito, Tomás Domingo-Moratalla, Agustín Domingo-Moratalla: Mediterranean autonomy: relational, narrative and careful. In. Ostium, vol. 19, 2023, no. 1.
The idea of autonomy has been emphasized in North American bioethics, understood mainly as non-interference in the decision-making of individuals. This “legal” concept of autonomy, which defends self-determination, is insufficient and partial. From a European Mediterranean perspective, autonomy can be understood not only as an exercise of freedom, but also as something that has to do with context, circumstances and relationship with others. For this reason, this paper proposes a vision of a Mediterranean autonomy from three categories: narrative, relational and careful. In this proposal we rely on Paul Ricoeur’s re-reading of the concept of autonomy.
Keywords: autonomy, narration, relational, careful, comprehensive care, Ricoeur, Mediterranean
The recognition of autonomy in the context of bioethics has been momentous. However, an important debate continues to emerge around the concept, as there are different ways of defining and understanding autonomy.
The introduction of this principle of autonomy was mainly influenced by the North American or Anglo-Saxon tradition, emphasising an individualistic vision in which it was a matter of defending the right of people to be respected in their beliefs and preferences. But it should be borne in mind that there are other meanings. Our aim here is to point to another concept of autonomy, which moves away from this more juridical approach to emphasise the more contextual, relational, narrative, emotional and care-related aspects, in a vision we call “Mediterranean autonomy”.
In an interesting article by Diego Gracia, the idea of the existence of a Mediterranean bioethics was raised. This idea has been debated and explored by other authors along the time. This Mediterranean bioethics is further away from these claims of autonomy and closer to models of social justice, which insist on contextualisation, on the relationship and on the understanding of the human being as part of a society and a community of values. Thus, more Aristotelian proposals are recovered that emphasising the idea of happiness and the good life, pointing to life as a project that is carried out among others and with others, where there is little room for more juridical perspectives and claims for rights.
It is precisely from this vision that we find the relevance of Paul Ricoeur’s proposal, who insists on this way of understanding ethics as a desire for a good life, with and for others, in just institutions. This means that the normative appears as a moment within a broader framework, enabling the transition between the desire for a good life and its concrete application.
This proposal for Mediterranean autonomy is also linked to the principles of European bioethics. A contribution made in 2000 in which, in contrast to the omnipresence and unquestionability of the North American principles of Beauchamp and Childress, four other different principles were defined. These principles were dignity, vulnerability, integrity and autonomy. As can be seen, the only common principle is that of autonomy. However, the understanding of autonomy is quite different. First of all, the cultural context of the creation of these principles is Mediterranean. The declaration of the principles was the result of a European project involving several countries that resulted in a document published in Barcelona (Spain). One of the promoters of this initiative was Peter Kemp, a direct disciple of Paul Ricoeur. Secondly, the understanding of autonomy is not possible without the other three principles among which it is situated. The autonomy referred to in the European principles is linked to the recognition of vulnerability and the need to protect integrity and respect dignity. This means that autonomy is reconfigured. The subject is not only conceived as a free and isolated individual who makes independent rational decisions, but is understood as someone who has a biography, who lives with others, who gives meaning to his or her decisions in a context.
This idea of the autonomous subject as an independent decision-maker is the one that has been most successful in bioethics. It ties in with the more legal tradition, which affirms the human being as a bearer of rights. Theoretically, it is based on the Kantian idea of a self-governing subject. And this model is the one most present in our western culture since the 18th century. But bioethics has understood it in a very restricted way as mere non-interference in the choices of others. This means that it does not delve into the idea of moral autonomy. It simply calls for respect and non-interference in people’s decisions. Autonomy is thus limited to an obligation of non-intrusion.
In fact, the well known Belmont Report identifies ”respect for persons” as one of the main moral principles and defines it in this way: ”To respect autonomy is to give weight to autonomous persons’ considered opinions and choices while refraining from obstructing their actions unless they are clearly detrimental to others”. The way of applying this idea of autonomy is through informed consent. ”Respect for persons requires that subjects, to the degree that they are capable, be given the opportunity to choose what shall or shall not happen to them. This opportunity is provided when adequate standards for informed consent are satisfied…. There is widespread agreement that the consent process can be analyzed as containing three elements: information, comprehension and voluntariness”.
Thus, there is no analysis of the condition of autonomous subject, but simply requirements for actions in which there is no coercion or any condition that limits the freedom of individuals.
Along with this legal concept of autonomy, Diego Gracia points to two other historical understandings of autonomy. There is a political concept, in which autonomy has been understood as the independence that a city (polis) has with respect to others, that is, that it is self-sufficient, capable of making its own laws.
There is a third way of understanding autonomy as a transcendental feature that defines human beings. It expresses their very condition. In contrast to the world of nature, which is determined, human beings move in an indeterminate world, a world of possibilities, a world of freedom. Therefore, a metaphysical sense is expressed here.
It is necessary to propose an authentically moral concept of autonomy which speaks of the self-determination of people, which emphasises that the management of one’s own life is self-directed, as an act of personal construction. This act must be understood as linked to others, to the circumstances in which we live, to the historical epoch and the social context. And also with the realisation of human vulnerability and fragility. Describing moral autonomy in this way implies understanding the human subject as a narrative being, a relational being and a being who cares and is cared for by others. In order to think about autonomy in this way, it is essential to pay attention to Paul Ricoeur’s proposal.
Ricoeur establishes a close connection between narrative and human life, between subject and narrative. Stories, narratives, refer to human life, and human life expresses itself narratively. This is possible because human life has a narrative structure.
The subject is made and constructed narratively. Narrative is one of the capacities that define the human being. Therefore, autonomy, a nuclear element of our personal being, is configured narratively.
Ricoeur says and repeats that narrative is a mediation between: 1) oneself and the world; 2) oneself and others; and 3) oneself with oneself. Narration introduces a dimension of reflexivity in human life that is necessary to constitute us as autonomous subjects. Autonomy is to be masters of ourselves, to narrate and project our life, which is only possible with a certain mastery of time. With narration we (somehow) dominate time. Ricoeur likes to repeat Socrates’ phrase: “a life that is not analysed is not worth living”. The way we analyse and reflect on our life is through narration, through taking ownership of it, through being masters of ourselves.
Autonomy is narrated, that is to say, linked to storytelling, to the capacity to tell and to tell ourselves, to project, to imagine and to imagine ourselves.
Of course, narratives are more than the possibility of telling our identity, or that our identity is not only narrative. They are two terms, life and narrative, which overlap without identifying each other.
The fundamental element for thinking about the subject (autonomy) narratively is the idea of plot. The plot is an operation, a configuring process. It consists of a synthesis of multiple events. What this synthesis does is to organise incidences (peripeteias) in a story; a concordant and discordant totality. It is also a game with time: from a chronological time we move on to a configured, plotted time.
An autonomous person is one who knows how to configure with diverse elements (vocation, desires, circumstances, projects, incidents) a story in which he/she can, in some way, recognise himself/herself. An autonomous being is one who can configure stories, his or her story. That is why we speak of narrated autonomy. Autonomous is a person who sets himself/herself, affirms himself/herself, affirming his/her story, a story; his/her own or one in which he/she recognises himself/herself.
In the concept of autonomy, in a narrative key, Ricoeur recognises two elements: on the one hand, the self that asserts itself, that gives itself a law, and a universe of meaning; on the other hand, someone is autonomous only if he/she can enter into a symbolic-narrative universe. This would be the minimum level of narrative autonomy, or autonomy in general.
To be autonomous is to be able to give oneself one’s own law, that is, to place oneself under a normative order, which presupposes the capacity to enter into a symbolic order. Ricoeur continues the Kantian approach but narratively read.
Narratives presuppose subjects (readers) capable of refiguring the text through their reading, making sense of it and interpreting it, and thus unfolding a world in front of the text. The reading subject is able to enter into the game of mimesis and catharsis proposed by the text.
Human life refers to narrative because of that inherent search for meaning, for intelligibility, for self-understanding. We seek meaning, order, stability. And the way to do this is through narrative. Moreover, our whole life is mediated, from the very beginning, by narratives. Human identity is a narrative identity.
This idea allows Ricoeur to move away from both substantive and monolithic identities such as those that think of the subject as a closed self, in a certain classical and Cartesian tradition (a self that asserts itself), and from traditions that affirm the diversity and plurality of the self, without identity, that affirm its inconsistency, in the style of Hume or Nietzsche. Faced with an absolute and deified self and a denied and degraded self, Ricoeur proposes a narrated self. And with him, we will speak of a narrated autonomy.
The idea of autonomy is a presupposition of moral life and at the same time a task. We think of ourselves as autonomous (without autonomy there is no ethics) and, at the same time, ethics education seeks a further development of autonomy. In the same way we can say that we are entangled in stories, the stories that others tell about me, I tell about others, and at the same time together. We are in narrative and we presuppose this narrative, or pre-narrative, capacity of the human being, but at the same time, we seek to be able to tell our own story. We move here to a higher level of narrative autonomy.
To tell our own story, to interpret ourselves narratively, is to seek our autonomy through storytelling. To be autonomous is to be able to commit oneself, to take risks, to decide, to live according to projects, to live in time, and this can only be done in narrative form.
However, this does not mean that we are the absolute builders of our history. Because, sometimes we are the writers of our stories, and we are the main character, or we play a role, or we identify with stories we tell and are told.
Thinking autonomy from the idea of narration (narrative autonomy) we achieve:
- Thinking the moral subject in time and circumstances (i.e. in a concrete way);
- Thinking the moral subject in relation: we are a function of the stories we are told and we are the storytellers of others; we are beings entangled in stories; we are beings in relation;
- To highlight the dimension of fragility and vulnerability; narration is a capacity, a power, but also impotence, suffering, impossibility; the capacity to narrate (narrative autonomy) is permeated by fragility and vulnerability.
- To tell and to tell ourselves; the narration tells us… and with the narration we tell…; we tell ourselves saying
Narration (also of ourselves) introduces emotional, sentimental, etc. elements.
Let us now turn to a second, complementary approach:
As indicated above, autonomy needs to be contextualised. Autonomy, understood as decision-making but also as the building of one’s own life based on self-determination, is carried out in relation to other people, which is why it is necessary to accept commitments and relationships, leaving behind the impartiality and absence of ties that defined the “liberal man”. This will result in a proposal for relational autonomy.
Relational autonomy understands the autonomous subject not as an individual being isolated from the world, but rather as someone who develops and gives meaning to his or her life within the framework of the relationship with other human beings and with the world. An anthropology based on the interrelation and interdependence of people is thus defended. This means becoming aware of one’s own vulnerability, that is, of the fragile condition of the human being, which is evident in its bodily and biological dimension, because it can be wounded, fall ill or die.
But also in the dimension of contact with others and the development of a moral conscience, elements which can also be damaged and which must be cared for and protected. This realisation of vulnerability calls for a revision of the idea of autonomy as it has been put forward. The individual is not an isolated subject but someone who is interdependent, i.e. someone who is recognised by others and who establishes relationships of responsibility and care with other people. Therefore, it is not possible to consider autonomy as detached from the contexts, frameworks and backgrounds that give meaning to and situate one’s own life. This abstract autonomy is unrealistic and far removed from the experience of people. Forgetting care and a more contextual and relational approach leads to an excessively impersonal and cold ethic, which, while adhering to its principles, does not attend to the reality of life.
In fact, Ricoeur argues that autonomy and vulnerability are two concepts that must go hand in hand. Life in common, that which is lived with others in the framework of just institutions, is only possible if a space of coexistence is built, that is, if justice ensures that our fragile and vulnerable life is respected and protected. The development of our narrative identity, the key to our autonomy, is thus only possible if there are certain guarantees for our survival.
To this it should be added that the construction of identity is not possible without the recognition of others. This is why it is impossible to understand the subject in isolation from his or her relationships, from his or her context, from the community of meaning in which he or she is inscribed. However, bioethics has ignored social issues and also gender issues, thus forgetting, in most cases, the belonging to a community or a society, in which can be found the identity of individuals takes on meaning and in which the roots of oppression or any other form of injustice. This is why it is necessary to correct this way of understanding autonomy by developing a different and richer concept. This new concept will be that of relational autonomy. The work done by feminist bioethics has been a key to the development of this idea.
Relational theories of autonomy attempt to analyse how social conditions of oppression can be internalised and thus succeed in undermining agents’ autonomy. This approach considers the autonomous individual decision-maker, who is the main character of many bioethical analyses, to be a fiction, because people are in networks of relationships, some of which are dependent on culture and socio-economic conditions, so that the presumed freedom of their choices is not such.
Feminism criticises this “narrow” conception of autonomy, in which agents can be considered autonomous as long as there are no disturbances that could seriously distort their reasoning capacity. People would be autonomous if there is no coercion or constraints, and they would be able to develop their life projects according to their preferences. From here, any interference in the interests or choices of autonomous subjects would be unacceptable. Relationships between citizens, and specifically in the context of the clinical relationship, try to avoid paternalism and therefore they must be based on non-interference.
However, this view ignores social conditions that can be oppressive and limit the autonomy of individuals. Although they do not produce pathologies or cognitive limitations, nor are they overt forms of coercion. Gender norms, for example, can have an impact on people’s motivational structures, implying an oppression that has been internalised to the point of eroding their autonomy. External constrictive conditions remove the power necessary for the exercise of autonomy. This is a relational concept of autonomy because it does not rely on how robust the psychological capacities of agents are, but rather asserts that external conditions make it impossible for them to be autonomous. The interpersonal becomes the key to understanding one’s own identity and the exercise of autonomy.
Some conceptions point out that autonomy is not linked to the traits of a mental state of capacity, but rather to the possibility for the agent to undergo a process of critical reflection. That is, in addition to competence, authenticity is required. And this second trait is historical, biographically constructed, and has to do with the possibility of expressing and defending preferences without generating any emotional distortion.
The concept of autonomy is thus relational, as it causally obeys a socialisation process in which there may be an oppression or a conditioning factor that hinders or obstructs the development of the capacity for critical reflection that is essential for decision-making. Moreover, autonomy admits degrees because this capacity for reflection can operate at different levels, depending on the processes of socialisation and the educational and cultural background. Certain forms of oppressive socialisation can truncate the options that a person considers viable, interfering with his or her autonomy. And, of course, emotions play an essential role in the concept of autonomy here. This is not a strictly cognitive or rational task. Feelings can act as “reasons” insofar as they also constitute a form of reflection on the values we care about and have to deliberate on.
From this perspective, the vision of universalistic discourses that defend an egalitarian dignity is completed, and attention is paid to difference and the particular. It is not only necessary to affirm that patients have the right to decide about their life and health, but it is also essential to pay attention to the personal dimension of life projects which, within a cultural and biographical framework in relation to other people, support and give meaning to autonomous decisions, and require a deliberative approach in the resolution of conflicts.
Of course, this is much more demanding and goes much further than the assertion of patients’ autonomy as a space of independence and free will. In short: Individuals claim their autonomy as an element of self-determination and freedom. However, this autonomy is contextualized, integrated in a network of relationships and in a cultural, geographical, social and meaningful framework. This is why autonomy is always in relation. In the first place, because the decisions of individuals generate a narrated biography, and in order to understand it, it is also necessary to comprehend the framework of relationships in which it is inscribed. Secondly, because autonomy requires guarantees of survival in the face of vulnerability, which depend on enabling and capacitating environments. Thirdly, because autonomy is exercised in a world of relationships with others. One more time: Ethics is a good life, with and for others in just institutions, as emphasized by Ricoeur. That is why the relationship with others is crucial.
To conclude, we can say that the key concepts of this relational and narrative approach to autonomy would be: that we are entangled, related to others; that this always takes place in a context and circumstances; and that there is a dimension of vulnerability that is consubstantial to the human being. Other ethical proposals have also highlighted these aspects. We approach it in a narrative and hermeneutic key, proposing a Mediterranean way of understanding autonomy. This way of understanding ourselves requires one more element: attention to the other and care.
An autonomy based on the ethics of care (careful autonomy), like the one we find in Ricoeur’s work, draws on two important sources or philosophical traditions. On the one hand, the source of Buber’s dialogic and relational tradition, on the other, the source of a critical hermeneutics built from K. Jaspers and H. G. Gadamer. Both are productive in all post-Carol Gilligan feminist ethics and converge in Levinas’s ethics of care and responsibility. From here we can distinguish between “spontaneous care” and “comprehensive care”. This distinction is important in the proposal of a Mediterranean Bioethics that has recently proposed ethics of care as a “generative ethics”, showing the productivity of “comprehensive care” as “generative care”.
In this approach, the principle of autonomy is not renounced, on the contrary, the critical and philosophical bases for a use are established. Faced with a naive and uncritical use of concepts such as autonomy and care, in Ricoeur we find a reflective and critical use of both terms. The concept of comprehensive care brings us closer to relational autonomy. The clarification of the concept of autonomy from vulnerability, fragility and relational finiteness put face and heart to a Mediterranean bioethics transformed.
In order to explain precisely the concept of autonomy used by Ricoeur, it is necessary to situate ourselves in the dialogical horizon opened up by Martin Buber’s philosophy for the 20th century. This horizon goes as far as the centrality of dialogue in the hermeneutics of Hans Georg Gadamer and we find it in the discourse ethics of J. Habermas and K. O. Apel. Between the philosophy of dialogue and the ethics of discourse we discover a narrative and relational concept of autonomy characterised by the finitude of the person, relationality, the search for authenticity and communicative responsibility. In the horizon to dialogical hermeneutics.
The starting point of the dialogical horizon is in the category of “between” when we think of the relationship “I” and “You”. This initiates a decentring of the “I” that had characterised modern philosophy. This horizon recovers a social, historical and cultural kantism that is not that of the first critique but that of the Doctrine of Virtue. Decentring is a shift towards integrating the world of life, history and circumstances into philosophical reflection. In this way we move from a monological freedom to a dialogical freedom, that is, from an isolated subjectivity to a communicated, fragile, historical and vulnerable subjectivity. This is why we say that the dialogical horizon implies rethinking autonomy from the facticity of existence, the fragility of the will and the finitude of reason. From here we can interpret such important works by Ricoeur as Finitude and Guilt or History and Truth.
The decentring of the subject does not imply unanchoring, detachment or rupture with the “I” or the “inner” dimension of personal life. This does not mean remaining in the paradigm of the philosophies of consciousness (monological or egological tradition) but its transformation from relation, action and two concepts dear to Ricoeur’s early works: commitment and testimony. Once the philosophy of consciousness has been replaced by a philosophy of testimony and commitment, the approach to Levinas is logical. Decentring is the fruit of the impact of otherness and asymmetry as new categories from which to think about autonomy. This produces an ethical transformation of the concept of autonomy. Integrating the conceptual power of Levinas, Ricoeur: (a) transforms the monological status of autonomy, autonomy is not only a point of departure but also a point of arrival; (b) recovers a relational and hermeneutic dimension of autonomy related to learning and the category of disciple; (c) transforms autonomy from otherness by rethinking in dialogical and hermeneutic terms The Golden Rule.
This transformation of autonomy does not dissolve or annul it from heteronomy but places it on a different level of rationality. Instead of situating us in a monological and speculative rationality, the hermeneutic transformation of autonomy situates us in a relational, interpersonal and responsibilising sphere. Human responsibility is approached from a new and transformed horizon because it is not only the present time that counts (agent autonomy) but time in all its dimensions. The autonomous person is not only an agent (present) or an act that represents a previously marked role (past). The autonomous person is also an “author”, i.e. a person in process, with new and unexploited possibilities, i.e. an open reality with its own possibilities of fulfilment. Relational autonomy demands at the same time to think of a renewed responsibility with the categories of agent, actor and author. A trait that we find in philosophers such as X. Zubiri, A. McIntyre and Ch. Taylor.
This relational autonomy and this renewed responsibility are not only aimed at the other (otherness) but also at nature and ourselves. Relational autonomy transforms the usual way of understanding the ethics of care that we find in the medical humanities, nursing, social work or, recently, in the feminist tradition (C. Gilligan). Care needs to be thought more radically because it not only questions the way of understanding social practices or habits (caring well), but also the way of understanding one’s own personal life (caring for oneself) and the way of caring for the environment (caring for nature). From this reflection on care, two important tasks open up for developing relational autonomy in the key of a “Mediterranean” autonomy:
The first of which is the distinction between “spontaneous care” and “reflexive care”. Care has always been an important category in moral philosophy because it was related to the way of carrying out inter-species breeding, the appropriation of one’s own nature, or even the diligent surveillance of what one took care of. Recall that in contemporary phenomenology Heidegger in Being and Time recovers the centrality of the “cure” or care of the self as a fundamental task for the new times of philosophy. This centrality of spontaneous care can be thought of from two opposing horizons, Heidegger’s with “care for oneself” and Lévinas’ with “solicitude for the other”.
The second is the proposal of the concept of “generative care” as a way of understanding comprehensive care halfway between the principle of autonomy and the others principles. Instead of approaching both terms in a principled and formal way, it approaches them in a historical, communicative and hermeneutic way. This opens the door to a justice with a face, attentive to vulnerability, proximity, compassion and solidarity. In this way, a practical, immediate and situated “relational autonomy” is put into practice and made operational. Generativity is a category of the phenomenological tradition (Husserl), of the psychology of moral development (E. H. Erickson) and is very close to that of “gerundivity” (X. Zubiri). Integral care is not only a practice that enables the growth of the other (otherness), but a practice that enables the growth of oneself (empowerment) in the whole of history (integrality).
Mediterranean autonomy, is it possible? Some conclusions
Autonomy in bioethics has multiple facets and ways of being understood. Although the most widespread and successful model is the North American model, which understands autonomy as a way of protecting the freedom of the individual in decision-making and thus safeguarding his or her self-determination, there are other possible ways of understanding autonomy from other cultural contexts. The North American model is insufficient in the light of other paradigms in which the centrality of the individual and his or her rights, although important, cannot be understood without paying attention to the biographical, historical, social and cultural context in which the individual develops his or her life.
The bioethics that is being constructed in Mediterranean Europe underlines other categories that are essential for understanding autonomy. The aim of this paper has been to highlight three of these categories that we consider fundamental: firstly, the narrative dimension, which affirms that the human being is biographical and is configured over time, thus developing the story of his or her own life. Secondly, the relational aspect of autonomy, that is, the assumption that human beings are interdependent and are not detached from the relationship with other people, which gives meaning and authenticity to the exercise of decision-making. And, thirdly, in the horizon of “comprehensive care”, rethinking the need to care and be cared for, as recognition of vulnerability, assumption of the equally needy condition of human life and the call to responsibility in the face of harm.
These three categories, which can be observed in the philosophy of Paul Ricoeur, summarized in his phrase “ethics is the desire for a good life, with and for others, in just institutions”, configure a way of understanding autonomy that assumes but goes beyond the merely juridical North American perspective.
The proposal outlined here rigorously assumes the contributions of the European Mediterranean tradition, placing it in dialogue with other perspectives. However, the question remains open as to the specificity of this approach, the relevance of further enrichment, and the feasibility of its application. The construction of a Mediterranean bioethics is an open and ongoing project.
B i b l i o g p r a p h y
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N o t e s
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