Moral Features of the Therapeutic Relationship with Adults: Dignity, Trust, Autonomy, Vulnerability, and Resilience

Abstract

Using dignity as a foundational value of morality, this article defines trust, autonomy, vulnerability, and resilience in relational terms. A fictional narrative illustrates these attributes as well as solidarity and care, two core tenets of relational ethics. Medicine and rehabilitation are described as moral enterprises with respect for persons at the core of our professional obligations to patients—namely, duties of care, trustworthiness, and loyalty. Clinically, promoting autonomy, decreasing vulnerability, and fostering resilience are encouraged, with particular emphasis on avoiding words or actions (or inactions) that could cause patients to feel discouraged or depersonalized. In conclusion, the purpose of our work with persons with aphasia and other communication disorders is to help them live their lives as fully as possible, despite their life-changing losses. Viewing our therapeutic relationships with them in relational moral terms can enhance our work.

Keywords

ethics - morality - dignity - therapeutic relationship - relational ethics

• References

• 1 American Speech-Language-Hearing Association. Code of Ethics [Ethics]; 2016 . Available at: www.asha.org/policy . Accessed March 15, 2020
• 2 Rogers C. A theory of therapy, personality and interpersonal relationships as developed in the client-centered framework. In: Koch S. , ed. Psychology: A Study of a Science. Vol 3: Formulations of the Person and the Social Context. New York, NY: McGraw Hill; 1959. [Cited by: McLeod SA. Carl Rogers; 2014. Retrieved January 21, 2020, from the Simply Psychology website: www.simplypsychology.org/carl-rogers.html ]
• 3 Byng S, Cairns D, Duchan J. Values in practice and practising values. J Commun Disord 2002; 35 (02) 89-106
• 4 LaPointe LL. Quality of life with aphasia. Semin Speech Lang 1999; 20 (01) 5-16 , quiz 16–17
• 5 Sarno MT. Aphasia rehabilitation: psychosocial and ethical considerations. Aphasiology 1993; 7 (04) 321-334
• 6 Sarno MT. Aphasia therapies: historical perspectives and moral imperatives. In: Duchan JF, Byng S. , eds. Challenging Aphasia Therapies: Broadening the Discourse and Extending the Boundaries. New York, NY: Psychology Press/Taylor & Francis; 2004: 19-32
• 7 Worrall L. Professionalism and functional outcomes. J Commun Disord 2006; 39 (04) 320-327
• 8 Barsky AJ. The iatrogenic potential of the physician's words. JAMA 2017; 318 (24) 2425-2426
• 9 Berg K, Askim T, Rise MB. What do speech-language pathologist describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study. Int J Speech Lang Pathol 2017; 18: 1-11
• 10 Brown K, Worrall LE, Davidson B, Howe T. Living successfully with aphasia: a qualitative meta-analysis of the perspectives of individuals with aphasia, family members, and speech-language pathologists. Int J Speech Lang Pathol 2012; 14 (02) 141-155
• 11 Dalemans RJP, de Witte L, Wade D, van den Heuvel W. Social participation through the eyes of people with aphasia. Int J Lang Commun Disord 2010; 45 (05) 537-550
• 12 Horner Catt J. The language of ethics in clinical practice. J Med Speech-Lang Pathol 2000; 8 (03) 137-153
• 13 Onishi SL, Hebert RS. The Stanford Prison experiment: implications for the care of the “difficult” patient. Am J Hosp Palliat Care 2016; 33 (01) 64-68
• 14 Parr S, Byng S, Gilpin S. Talking About Aphasia: Living with Loss of Language After Stroke. Buckingham, UK: Open University Press; 1997
• 15 Patel JJ. The things we say. JAMA 2018; 319 (04) 341-342
• 16 Roberts JL, Weeks E. Stigmatizing the unhealthy. J Law Med Ethics 2017; 45: 484-491
• 17 Haque OS, Waytz A. Dehumanization in medicine: causes, solutions, and functions. Perspect Psychol Sci 2012; 7 (02) 176-186
• 18 Lysaught MT. Respect: or, how respect for persons became respect for autonomy. J Med Philos 2004; 29 (06) 665-680
• 19 Jennings B. Relational ethics for public health: interpreting solidarity and care. Health Care Anal 2019; 27 (01) 4-12
• 20 Gilligan C. In a Different Voice: Psychological Theory and Women's Development. Cambridge, MA: Harvard University Press; 1982
• 21 Rendtorff JD. Basic ethical principles in European bioethics and biolaw: autonomy, dignity, integrity and vulnerability--towards a foundation of bioethics and biolaw. Med Health Care Philos 2002; 5 (03) 235-244
• 22 Kant I. Groundwork of the Metaphysics of Morals (rev.). [Gregor M, Timmermann J, trans, ed.] Cambridge, UK: Cambridge University Press; 2012
• 23 Respect. Stanford Encyclopedia Philos. February 18, 2018. Available at: https://plato.stanford.edu/entries/respect . Accessed January 21, 2020
• 24 Korsgaard CM. Introduction. In: Kant I. , ed. Groundwork of the Metaphysics of Morals (rev.). [Gregor M, Timmermann J. trans, ed.] Cambridge, UK: Cambridge University Press; 1785. /2012: ix-xxxvi
• 25 Byers P. Dependence and a Kantian conception of dignity as a value. Theor Med Bioeth 2016; 37 (01) 61-69
• 26 Rodríguez-Prat A, Monforte-Royo C, Porta-Sales J, Escribano X, Balaguer A. Patient perspectives of dignity, autonomy and control at the end of life: systematic review and meta-ethnography. PLoS One 2016; 11 (03) e0151435
• 27 Frank AW. First-person microethics: deriving principles from below. Hastings Cent Rep 1998; 28 (04) 37-42
• 28 Truog RD, Brown SD, Browning D. , et al. Microethics: the ethics of everyday clinical practice. Hastings Cent Rep 2015; 45 (01) 11-17
• 29 Tauber AI. From the self to the other: building a philosophy of medicine. In: Grodin MA. , ed. Meta Medical Ethics: The Philosophical Foundations of Bioethics. Kluwer Academic Pub; 1995: 157-196
• 30 Pellegrino ED. Toward a reconstruction of medical morality. Am J Bioeth 2006; 6 (02) 65-71
• 31 Thomasma DC. The vulnerability of the sick. Bioeth Forum 2000; 16 (02) 5-12
• 32 Wolfensberger M, Wrigley A. Trust in Medicine: Its Nature, Justification, Significance, and Decline. New York, NY: Cambridge University Press; 2019
• 33 Barnard D. Vulnerability and trustworthiness. Camb Q Healthc Ethics 2016; 25 (02) 288-300
• 34 Nys T. Autonomy, trust, and respect. J Med Philos 2016; 41 (01) 10-24
• 35 Jones K. But I was counting on you!. In: Faulkner P, Simpson T. , eds. The Philosophy of Trust. Oxford, UK: Oxford University Press; 2017: 90-108
• 36 Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. New York, NY: Oxford University Press; 1993
• 37 Baier A. The possibility of sustaining trust. In: Pauer-Studer H. , ed. Norms, Values, and Society. Boston, MA: Kluwer Academic Publishers; 1994: 245-259 . [Cited by: Wolfensberger M, Wrigley A. Trust in Medicine: Its Nature, Justification, Significance, and Decline. New York, NY; 2019;164]
• 38 U.S. Department of Health, Education and Welfare, The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research; 1979 . Available at: hhs.gov/ohrp/regulations-and-policy/Belmont-report/index.html. Accessed March 26, 2020
• 39 Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 7th ed. New York, NY: Oxford University Press; 2013
• 40 Carrese JA. Refusal of care: patients' well-being and physicians' ethical obligations: “but doctor, I want to go home”. JAMA 2006; 296 (06) 691-695
• 41 Carling-Rowland A, Black S, McDonald L, Kagan A. Increasing access to fair capacity evaluation for discharge decision-making for people with aphasia: a randomized controlled trial. Aphasiol 2014; 28 (06) 750-765
• 42 Ferguson A, Duffield G, Worrall L. Legal decision-making by people with aphasia: critical incidents for speech pathologists. Int J Lang Commun Disord 2010; 45 (02) 244-258
• 43 Horner J, Modayil M, Chapman LR, Dinh A. Consent, refusal, and waivers in patient-centered dysphagia care: using law, ethics, and evidence to guide clinical practice. Am J Speech Lang Pathol 2016; 25 (04) 453-469
• 44 Cassell EJ. Life as a work of art. Hastings Cent Rep 1984; 14 (05) 35-37
• 45 Jennings B. Reconceptualizing autonomy: a relational turn in bioethics. Hastings Cent Rep 2016; 46 (03) 11-16
• 46 Mackenzie C. The importance of relational autonomy and capabilities for an ethics of vulnerability. In: Mackenzie C, Rogers W, Dodds S. , eds. Vulnerability: New Essays in Ethics and Feminist Philosophy. New York: Oxford University Press; 2014: 33-59
• 47 Fineman MA. The vulnerable subject: anchoring equality in the human condition. Yale J Law Fem 2008; 1 (20) 1-23
• 48 Danis M, Patrick DL. Health policy, vulnerability, and vulnerable populations. In: Danis M, Clancy C, Churchill LR. , eds., Ethical Dimensions of Health Policy. New York: Oxford University Press; 2002: 310-334
• 49 Hughes V. Stress: the roots of resilience. Nature 2012; 490 (7419): 165-167
• 50 Lotz M. Vulnerability and resilience: a critical nexus. Theor Med Bioeth 2016; 37 (01) 45-59
• 51 Haglund ME, Nestadt PS, Cooper NS, Southwick SM, Charney DS. Psychobiological mechanisms of resilience: relevance to prevention and treatment of stress-related psychopathology. Dev Psychopathol 2007; 19 (03) 889-920
• 52 Robertson I, Cooper CL. Resilience. [Editorial] Stress Health 2013; 29 (03) 175-176
• 53 Musser B, Wilkinson J, Gilbert T, Bokhour BG. Changes in identity after aphasic stroke: implications for primary care. Int J Family Med 2015; 2015: 970345
• 54 Jennings B. Healing the self. The moral meaning of relationships in rehabilitation. Am J Phys Med Rehabil 1993; 72 (06) 401-404
• 55 Lieberman A. Counseling issues: addressing behavioral and emotional considerations in the treatment of communication disorders. Am J Speech Lang Pathol 2018; 27 (01) 13-23
• 56 Phillips DT, Mendel LL. Counseling training in communication disorders: a survey of clinical fellows. Contemp Issues Commun Sci Disord 2008; 35: 44-53
• 57 Campelia G, Tate T. Empathetic practice: the struggle and virtue of empathizing with a patient's suffering. Hastings Cent Rep 2019; 49 (02) 17-25