Relational Autonomy, Maternalism, and the Nocebo Effect

Abstract

In their target article, Menkes et al. suggest that the nocebo effect, in which an individual experiences an adverse effect of medical treatment due to negative expectations, occasions a dilemma between autonomy and nonmaleficence. They work to resolve the dilemma by arguing that in some cases, nonmaleficence outweighs autonomy. In this commentary article, we suggest that the concept of autonomy presumed to underlie informed consent practices is at the root of this predicament – not a pro tanto conflict between autonomy and nonmaleficence. We propose that if the concept of relational autonomy (understood in terms of autonomy competencies) is utilized instead, this conflict dissolves. To concretize this conceptual point, we describe how the types of informed consent practices described as untenable by the authors (in which disclosure is calibrated to the individual patient) are actually widely practiced in Japan. Elucidation of these practices requires a wider lens on informed consent practices that includes support staff such as nurses and medical social workers as well as family members. These practices, best understood as maternalistic, are ethically justifiable from a relational autonomy perspective. As we argue, there are good reasons to approach the nocebo effect from this perspective; doing so both dissolves the autonomy/best interests dilemma and grounds concrete suggestions for reducing the nocebo effect.