Michael Rost, Eva de ClercQ, Bernice Elger
When writing about autonomy, we are aware that we are “join[ing] a conversation that has been ongoing long before [we] arrived and will continue long after [we]’ve departed” ( p. xi). We do not intend to have the final say, nor do we lose sight of the genuine contestability of the concept of autonomy. Rather, the aim is to inform the debate by sketching the position of the Swiss-German psychologist Arno Gruen, former professor of psychology at Rutgers University New Jersey and practicing psychoanalyst in Switzerland, and to apply his view to paediatric practice. Gruen died in 2015, leaving behind a substantial body of work on autonomy including his ground-breaking first book “The Betrayal of the Self. Fear of Autonomy in Men and Women” . In the following, preliminary remarks shall be devoted to autonomy to contextualise his approach.The principle of autonomy (in paediatrics)
The principle of autonomy (Greek: auto: self, nomos: law) is based on the recognition that every human being is equal in dignity and usually refers to the “right to make decisions and act on them freely and without interference” ( p. 252). Thus, a patient can both consent to and refuse treatments. In bioethics, it is widely accepted that autonomy is qualified by decision-making capacity, which is essentially understood as a cognitive trait within the person . Since children are usually considered to lack such capacity, their decision-making rights are limited and parents act as surrogates . Still, the child should be involved in a developmentally appropriate way . Critiques have lamented that such a capacity-centred and individualistic understanding of autonomy not only disregards individuals’ embeddedness into relationships, but also devalues highly dependent persons (e.g., children), and therefore have proposed to recognise autonomy as socially determined (e.g., relational autonomy) . Consequently, additional, non-cognitive determinants of autonomy need to be considered (e.g., relational, emotional) to do more justice to children.
Autonomy does not only represent a right to which every human being is inherently entitled. Exercising autonomy contributes to the development of human faculties, such as observation, reason and judgement, and is thus constitutive of human well-being . However, this constituting function can only come about if there is capacity for autonomy, which is different from the aforementioned decisional capacity as a proposed prerequisite for autonomy. Whereas the later refers to a rather cognitive trait, the former refers to the ability to be autonomous, which needs to be acquired and developed, or to say it with the words of the philosopher K. A. Appiah – “autonomy seems to entail a lot more than just being left to your own devices; it sounds like a capacity we need to cultivate” ( p. 37). Gruen discussed how capacity for autonomy can be portrayed, and how it can and why it should be cultivated.Gruen’s approach to autonomy 
In Gruen’s view, the capacity to be autonomous has to be developed from early infant days onwards and depends on the child’s life situation. Hence, it requires a given possibility to develop autonomy: a child has to be put in a situation where she or he learns that there is something to be learned with respect to her or his own feelings and needs. Therefore, parents have to empathise with the child, have to become aware of the child’s attempts to express her or his needs and, finally, have to respond to them. In that way, a child learns that her or his needs are significant in so far as they are recognised and responded to and, consequently, she or he learns to recognise and to identify with own feelings and needs. Otherwise, children “learn that there is nothing to be learned. They learn not to make their own reactions the point of departure for their development. This experience (…) is the decisive factor in the failure to develop autonomy” ( p. 4). In this case the child renounces and betrays her or his true self, desperately adapts to the external world, and surrenders to the will of others to earn their (conditional) love. Moreover, Gruen argues that the submissive child will start to strive for power and learn to manipulate relationships and the environment, which are henceforth mainly seen through the lens of domination. The result is a distorted development, which may persist throughout life. It is of particular relevance to respond with empathy and comfort to a child’s feelings of vulnerability and pain (not with domination and moral authority to control the child), so that the child learns that these feelings are not a sign of weakness or something to be ashamed of, but that feeling vulnerable is permissible and that painful feelings are part of one’s inner self . If a child fails to accept these emotions, then she or he will use power over others as a way to escape from such feelings.
Being autonomous, as understood by Gruen, is a twofold emotional capacity. First, an individual needs access to his or her inner voice, and needs to be “able to experience freely one’s own perceptions, feelings, and needs” ( p. xv), a capacity which can be developed as described above: through empathetic parental care. Second, these feelings need to be integrated within the psyche of the individual. This mental procedure of harmonising all aspects of the personality for Gruen results in the attainment of personal integration. Gruen understands autonomy thus as the “state of integration in which one lives in full harmony with one’s feelings and needs” ( p. 1). Correspondingly, to be autonomous means to (1) experience (not suppress) and (2) integrate (not dissociate) own feelings and needs (fig. 1). In this state of self-acceptance, a person has access to life-affirming emotions, may they be negative (e.g. sorrow, despair) or positive (e.g. joy, confidence).
It is noteworthy that Gruen’s perspective inheres a “choice that is made for children (…) whether the development of the self (…) will be formed by inner or by outer forces – in other words, whether they will live an autonomous existence or one dependent on external stimulation” ( p. 6). If the child is allowed to make these formative experiences, she or he (as well as the later adult) is likely to be able to be autonomous, which, as Gruen emphasises, “does not result from having ideas of one’s own importance, nor from the necessity for independence” ( p. xv).Significance for paediatrics
The lesson we can learn is to rethink autonomy as a capacity which unfolds within the individual. In medicine, autonomy is commonly equated with „the state of being independent, free, and self-directing”  and with “the right to hold views, to make choices, and to take actions based on personal values and beliefs” ( p. 63). Such understandings relate to social situations (making decisions independent of and free from interferences) in which persons show behaviour and thereby express preferences (self-directing through taking actions). Following Gruen, this represents a mistaken understanding, because autonomy occurs within the individual, prior to making choices and taking actions, and is, in the form of the abovementioned state of personal integration, a sine qua non of any truly self-governed choice or action. Autonomy, as understood by Gruen, is different from and precedes what is frequently equated with autonomy.
Although it is mainly a parental responsibility to create situations in which children can develop autonomy and a societal duty to facilitate this endeavour, practitioners can and should support parents in developing children’s autonomy. Certainly, Gruen’s approach to autonomy in children is worth utilising in paediatric practice, but also beyond in daily interaction with children. For paediatric healthcare professionals, the imperatives are manifold: support the development of autonomy. Respond unconditionally to children’s needs and feelings, thereby enhance their capacity to experience them. Actively encourage children to accept their needs and feelings, thereby enhance their capacity to integrate them. In concrete terms, parents and paediatric healthcare professionals can meaningfully operationalise Gruen’s viewpoint by allowing and encouraging the child to express her or his whole spectrum of emotions, particularly feelings of vulnerability and pain. The younger the child is, the more important it is to support the development of children’s integrative capacity, since children become less susceptible for such formative experiences with increasing age.
Gruen’s perspective adds to our current understanding of children’s autonomy, first, because he offers a different understanding and, second, because he considers how autonomy can be developed. His view is especially valuable, since the possibility and responsibility to enhance autonomy in children might be neglected in paediatric practice owing to a focus on assessing whether or not the child has decisional capacity (fig. 1). A child who is attuned to her or his inner self is likely to reach her or his full potential. As Martha Welch correctly points out “not only can [such a child] maneuver through a hostile environment, [she or] he can fulfill [her or] his potential, [her or] his dreams, and enjoy the journey as well.” ( p. 139). Ultimately, allowing children an autonomous self by allowing them to develop in an emotionally integrated way means to enhance their personal health.FINANCIAL DISCLOSURE
The study was supported by the Swiss National Science Foundation, National Research Programme 67 “End of Life”, Grant-No. 406740_139283/1. The authors of this study have no relevant financial relationships to disclose.POTENTIAL COMPETING INTERESTS
The authors declare no conflicts of interest.AUTHOR CONTRIBUTIONS
Michael Rost developed the idea for this Perspective and took the lead in writing the manuscript. Eva De Clercq and Bernice Elger provided substantial contributions to the interpretation and application of the theoretical background and to the focus of the article. They read and critically revised the whole manuscript. All authors approved the final version of the manuscript for submission.
Institute for Biomedical Ethics, University of Basel, Switzerland
Eva de ClercQ
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