The American Journal of Bioethics

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/uajb20

The Centrality of Relational Autonomy and

Compassion Fatigue in the COVID-19 Era

Kellie R. Lang & D. Micah Hester

To cite this article: Kellie R. Lang & D. Micah Hester (2021) The Centrality of Relational Autonomy
and Compassion Fatigue in the COVID-19 Era, The American Journal of Bioethics, 21:1, 84-86,
DOI: 10.1080/15265161.2020.1850914

To link to this article: https://doi.org/10.1080/15265161.2020.1850914

Published online: 29 Dec 2020.

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84 CASE COMMENTARIES
enough” in order to allow for the presence of support
persons, so that “perfect” infection prevention
approaches do not get in the way of ethically sound,
well-informed, autonomous decision-making. These are
definitely “other-than-normal” circumstances, and as
such require flexibility, creativity, and patience above all.
THE AMERICAN JOURNAL OF BIOETHICS
2020, VOL. 21, NO. 1, 84–86
https://doi.org/10.1080/15265161.2020.1850914
CASE COMMENTARIES
The Centrality of Relational Autonomy and Compassion Fatigue in the
COVID-19 Era
Kellie R. Langa and D. Micah Hesterb
a
Kaiser Permanente South Bay Medical Center; bUniversity of Arkansas for Medical Sciences/College of Medicine
As given, the case presents at least two questions for
the ethics consultant to explore: (1) to what extent
should Declan’s parent, Karesha, be involved in his
health care decisions, and (2) why is the staff reluctant
to engage with Declan’s mother?
To get at an answer to the first question, any ethics
consultation must explore Declan’s autonomy interests,
since he is a young adult (presumably) with decision-
making capacity. However, what those interests are is
unknown in the case as given. Thus, fundamental to the
consult is a discussion with Declan himself. The consult
must take the time to learn from and about Declan in
order to determine what his interests are and how to
support him in exercising those interests.
While autonomy is often characterized by the rhet-
oric of individuality and liberty, that betrays a kind of
insular and atomic conception of individuals; good
work in pragmatist, feminist, and narrative ethics has
argued (convincingly) that this conception is mis-
guided. Instead, alternate conceptions, such as rela-
tional autonomy, better capture reality. Relational
autonomy recognizes the value and necessity of rela-
tionships and social surroundings to one’s develop-
ment and expression of autonomy (Dove et al. 2017).
It is interdependence, not independence that is signifi-
cant for relational autonomy (Dove et al. 2017).
Declan lives at home with his mother and has been
challenged by his cancer for many years, prior to him
CONTACT Kellie Lang kellielang@mac.com Kaiser Permanente South Bay Medical Center, Harbor City, CA 90710-3518, USA.
ß 2021 Taylor & Francis Group, LLC
REFERENCES
Reust, C. E., and S. Mattingly. 1996. Family involvement in
medical decision making. Family Medicine 28 (1):39–45.
Walker, M. U. 1993. Keeping moral space open: New
images of ethics consulting. The Hastings Center Report
23 (2):33–40.
becoming an adult. While we do not know what role
he wants his mother to play in his health care, it
would be a mistake to start from the position that he
would want to be wholly independent and free from
her help and support. Of course, this may be the case,
but Karesha has told the ethics consultant that Declan
is “passive” and does not know answers to her ques-
tions about his care. It remains, then, to be explored
whether this “passivity” is his personality or an
attempt to prevent her from obtaining this informa-
tion. Declan should be encouraged to consider and
communicate how involved he would like his mother
to be in his medical care. While it may be true that
Karesha, like other parents of young adults with can-
cer, has difficulty allowing their child to make medical
decisions independent of their parental input, it is
also true that young adults rely on family members
for support that includes involvement in the medical
decision-making process (Bourdeanu & Cannistraci
2018). As such, clarifying the role of his mother with
him and getting clear direction from Declan would be
another aspect of his exercising his autonomy: he
chooses the extent that he wants Karesha to
be involved.
While pursuing Declan’s autonomy interests is cen-
tral to the case, and again, much work must be done
by the consultant through conversations with Declan,
Karesha, and the team to understand better the extent

of those interests in relation to his current condition,
the consultant must take time to shine a light on an
often under-explored and under-valued consider-
ation—namely, what is driving the staff’s responses to
Karesha’s involvement?
In the case we learn that some staff are dismissive
of Karesha’s concerns, ignoring her requests for infor-
mation, and they hold the perspective that Karesha is
“never satisfied.” They note that they have “limited
time to attend to her demands,” which raises the
question for the consultant—what actions/statements
by Karesha are being characterized by staff as
“demands,” why are they characterized in that way by
staff? Without further information it does not seem
unusual or problematic to have a parent involved in a
young patient’s care, particularly a parent of a young
adult with cancer diagnosis, who has been living with
that disease from the time he was a minor. Add to
this context that we live in times of COVID-19, and
Karesha is trying to navigate all this when her access
is limited not only by staff but by circumstances, and
it does not seem that Karesha’s questions and desire
to be involved are without real warrant. So, again, we
might ask why the staff is so resistant. One possibility,
often overlooked, is that, given the stressors of caring
through contingency standards of care and pandemic-
related deaths, staff may be experiencing/suffering
from compassion fatigue.
“Compassion fatigue” is a phenomenon where
someone experiences stress associated with witnessing
trauma or suffering of patients but has lost resilience
to cope well with those stressors (Cocker and Joss
2016). Compassion fatigue, then, is “a state of exhaus-
tion and dysfunction biologically, psychologically, and
socially as a result of prolonged exposure to compas-
sion stress and all it invokes” (Cocker & Joss 2016,
citing Figley, C. 1995) and is characterized by irritabil-
ity, inability to feel empathy, and impaired ability to
care for patients (Cocker and Joss 2016).
Compassion fatigue has been identified as a serious
risk for health professionals, particularly nurses, as a
direct result of the demands of the COVID-19 pan-
demic (Alharbi, Jackson, and Usher 2020). Lachman
(2016) states, “If nurses have no outlet for expression
of their feelings, the feelings likely either will implode
into physical or emotional symptoms or explode into
short tempered outburst or resentment of demands.”
With defenses down and stressors high, one expres-
sion of compassion fatigue may be resentment of the
requests that Karesha is making of the team, leading
to characterize such requests for involvement and
information as “demands” that further exhaust the
THE AMERICAN JOURNAL OF BIOETHICS 85
staff (Lachman 2016; Cocker and Joss 2016). Further
evidence for the possibility of compassion fatigue as a
source of concern in this case is that the team sug-
gests that it has “limited time” to handle Karesha’s
concerns. Of course, under the pressures of how clin-
ical care is provided during the COVID-19 pandemic,
a provider’s time does have new limits, and to cite
time as a factor may also bespeak a general pressure
brought on by the circumstances more so than a spe-
cific pressure brought on by Karesha’s inquiries.
While it is not the responsibility of the ethics con-
sultant to provide therapy for compassion fatigue, it is
useful to know some ways of dealing with it in order
to offer ideas to provide staff. Strategies to address
potential for compassion fatigue begin with helping
staff distinguish between any specific and real chal-
lenges that arise working with Karesha from more
general challenges that push on their overall attitudes
in their work. Using techniques such as debriefings
after significant emotional events; providing mecha-
nisms to listen to the concerns of staff, and addressing
self-care (Alharbi, Jackson, and Usher 2020; Lachman
2016) may prove useful in reducing the “fatigue.”
Additionally, it can be important to promote the use
of employee assistance programs in order to offer
therapeutic support—along with support groups
offered by pastoral care counselors or behavioral
health specialists (Lachman 2016).
CONCLUSION
With so little explicit in the case, an ethics consultant
has a good deal of work to do in order to get the stories
that will serve as the basis of any recommendations that
may arise. There are any number of possible responses,
depending on what the consultant learns through con-
versations with stakeholders. Declan may find his
mother to be overwhelming in her approach to his care
and desire that she not be involved, but of course, the
opposite may be the case. Karesha may truly be
demanding more than is due given the circumstances
and her role and authority. The team may hold biases—
racial, social, psychological, cultural—that affect how
they respond to Karesha. None of this is known in the
case as given, and thus requires the consultant to get in
and learn a great deal.
The point of this commentary is simply to high-
light that beyond the important considerations of
respecting the relational autonomy of the patient, and
exploring what “respect” might mean in this particular
case, an ethics consultant should be keenly aware of
the stressors (such as compassion fatigue) that affect
86 CASE COMMENTARIES
the healthcare team’s responses in their daily work
and, particularly, during the challenging times that
COVID-19 has created for all.
REFERENCES
Alharbi, J., D. Jackson, and K. Usher. 2020. The potential
for COVID-19 to contribute to compassion fatigue in
critical care nurses. Journal of Clinical Nursing 29
(15–16):2762–3. doi:10.101111/jocn.15314.
Bourdeanu, L., and P. Cannistraci. 2018. Challenges and
role changes in caring for adult children with cancer.
Journal of Advanced Practice Oncology 9 (6):634–8.
Cocker, F., and N. Joss. 2016. Compassion fatigue among
healthcare, emergency and community service workers: A
systematic review. International Journal of Environmental
Research and Public Health 13 (6):618. doi:10.3390/
ijerph13060618.
Dove, E. S., S. E. Kelly, F. Lucivero, M. Machirori, S.
Dheensa, and B. Prainsack. 2017. Beyond individualism:
Is there a place for relational autonomy in clinical prac-
tice and research? Clinical Ethics 12 (3):150–65. doi:10.
1177/1477750917704156.
Lachman, V. D. 2016. Compassion fatigue as a threat to
ethical practice: Identification, personal and workplace
prevention/management strategies. MedSurg Nursing 25
(4):275–8.