doi: 10.1111/j.1369-7625.2010.00638.

A relational perspective on autonomy for older

adults residing in nursing homes
Susan Sherwin PhD FRSC* and Meghan Winsby MA
*University Research Professor Emeritus, Department of Philosophy, Dalhousie University, Halifax, NS, Canada and Doctoral
Student, Department of Philosophy, University of Western Ontario, London, ON, Canada

Abstract
Correspondence Aim To review critically the traditional concept of autonomy,
Susan B. Sherwin PhD, FRSC propose an alternative relational interpretation of autonomy, and
University Research Professor
Emeritus
discuss how this would operate in identifying and addressing ethical
Department of Philosophy issues that arise in the context of nursing home care for older adults.
6135 University Avenue
Dalhousie University Background Respect for patient autonomy has been the corner-
Halifax stone of clinical bioethics for several decades. Important though this
NS B3H 4P9
principle is, there is debate on how to interpret the core concept of
Canada
E-mail: ssherwin@[Link] autonomy. We review the appeal of the traditional approach to
autonomy in health care and then identify some of the difficulties
Present address: Meghan Winsby, with this conception.
3137 McIver Rd., Westbank, BC V4T
1E7, Canada. Methods We use philosophical methods to explain and discuss the
Accepted for publication traditional and relational conceptions of autonomy and we
27 July 2010 illuminate our discussion with examples of various contextual
Keywords: nursing homes, older applications.
adults, relational autonomy
Conclusion We support the relational conception of autonomy as
offering a richer, more contextualized understanding of autonomy
which attends to the social, political and economic conditions that
serve as background to an agentÕs deliberations. To illuminate these
ideas, we discuss the situation of frail older adults who frequently
find their autonomy limited not only by their medical conditions but
also by cultural prejudices against the aged and by the conditions
commonly found within the nursing homes in which many reside.
We propose ways of improving the relational autonomy of this
population.

autonomyÕ refers to a cluster of approaches to

Introduction
autonomy, which emphasize (rather than ignore)
Respect for patient autonomy has been the the socially embedded nature of agents. In this
cornerstone of clinical bioethics for several article, we shall briefly review the traditional
decades. Important though this principle is, interpretation of autonomy in bioethics and
there is debate on how to interpret the core explain how a relational approach offers a
concept of autonomy. In recent years, various richer, more contextualized understanding.
theorists have proposed relational alternatives to Where the traditional approach focuses on the
the traditional view of autonomy.1 ÔRelational capacity of the patient and on the clinicianÕs

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 A relational perspective on autonomy for older adults, S Sherwin and M Winsby 183

obligation to provide adequate information, a authority over decisions affecting his ⁄ her own
relational approach asks that we attend also to healthcare and body, with the earlier Ôdoctor
the social, political and economic conditions knows bestÕ approach largely replaced by a
which serve as background to an agentÕs delib- patient authority view (at least within North
erations. We shall discuss the value of taking America). While all patients are entitled to have
social context into account – particularly pat- their autonomous decision making respected,
terns of discrimination and inequality – as we they must be sufficiently competent to make well-
evaluate some of the key background conditions founded decisions that reflect their own values.
against which choices are made, exploring how Unfortunately, many older residents of nursing
this alternative conception of autonomy can homes are afflicted by dementia or other condi-
improve our understanding of caregiving tions that have reduced their level of compe-
responsibilities. To illuminate these ideas, we tency. In such cases, clinicians are expected to
will discuss the situation of frail senior adults honour any clear instructions that were given
who reside in nursing homes and frequently find when the patient was competent. Absent such
their autonomy limited not only by their medical direction, they must rely on the decisions of those
conditions but also by cultural prejudices who have legal authority to decide on the
against older adults. patientÕs behalf; ideally, such surrogates will be
guided by appreciation of the patientÕs values.
The principal mechanism for respecting
Traditional approach to autonomy
patient autonomy in clinical settings is a process
The ideal of respect for patient autonomy in of informed consent, where competent patients
clinical encounters is of central theoretical and (or the surrogates of non-competent patients)
practical concern to bioethicists, patients, clini- express formal agreement with a proposed ther-
cians and caregivers. The attraction of this ideal apy after receiving clear information regarding
is readily understood and accepted in Western all relevant information. Such decisions are to be
democracies where respect for personal auton- made voluntarily, without external coercion or
omy figures centrally in social and political dis- efforts to distract a patient from focus on his ⁄ her
course in many domains: it is promoted in own welfare. Informed consent includes a right
moral, legal and political spheres as key to to informed refusal since respect for autonomy
ensuring that individuals live lives that are, to also entails respecting patientsÕ wishes regarding
the greatest extent possible, of their own medical non-interference. In practice, however,
choosing (i.e. in accordance with their own informed consent procedures are often reduced
interests, goals and life plans). As such, the to the technicality of obtaining a signature on a
familiar ideal of autonomy common to main- generic form, sometimes with little attention to
stream philosophical, legal and political theory the decision makerÕs actual understanding or
is grounded in traditional liberal ideology. To be wishes. Properly executed, however, informed
autonomous is to be a Ôfree, self-governing consent serves as a mechanism for protecting
agentÕ.2 (P.143) Autonomous agents make deci- patient autonomy.
sions that are uncoerced and that best express Personal autonomy runs into particular risk in
the outcomes of their own deliberative processes. the clinical setting, owing in large part to the
The dominant cultural ideal of such agents increased dependence and vulnerability that fre-
envisions them as independent, rational, and quently accompany illness. When ill, patients
self-interested persons.2 often experience greater dependency, and with it,
It is widely accepted that patients have a right a greater likelihood that they will have their
to make significant decisions regarding their lives interests and values overridden by others. For
and bodies and hence, their health care. example, there is a significant risk of paternalism
ÔAutonomyÕ in clinical contexts is generally where clinicians are tempted to substitute their
understood to refer to an individual patientÕs own judgment for that of a patient, particularly

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184 A relational perspective on autonomy for older adults, S Sherwin and M Winsby

when they feel that they have a better insight into range of barriers to autonomous choice than is
that patientÕs medical needs than the patient usually acknowledged in autonomy discussions.
himself ⁄ herself, and they seek to ensure the best In particular, it considers the embodied social
medical outcome. Moreover, patients may feel location and experience of patients relevant to
constrained from insisting on their own wishes for assessments of autonomy. Rather than theorizing
fear that questioning or rejecting their doctorsÕ about abstract individuals, conceived of simply as
advice may result in abandonment. In addition, rational deliberators, we recognize that persons
some patients are susceptible to abuse or exploi- are essentially social beings, whose distinct iden-
tation in the service of othersÕ financial, academic tities are developed and maintained within a
or social interests. All of these problems are complex web of social relations.1 The particular
exacerbated for patients who reside in nursing social location of a given individual is influential
homes, particularly when they are subject to ste- in establishing his ⁄ her priorities, concerns, values
reotypical assumptions about the connection and beliefs about himself ⁄ herself. Moreover, it
between old age and reduced competency. often determines a personÕs opportunities to
While efforts to protect patient autonomy develop the necessary skills for exercising
provide a means of avoiding some of the ways in autonomy.3
which patients risk losing control over impor- Autonomy admits of degrees, such that a
tant decisions in their lives, there is often a sig- person can have more or less autonomy. More-
nificant gap between the ideal of independent, over, the ways in which autonomy can be limited
competent, fully informed, voluntary decision are multiple: there are many different types of
making and the actual conditions in which factors that can interfere with a personÕs ability
patients must choose, even when patients are to pursue maximal autonomy. On this interpre-
living independently. For example, the ideal of tation, then, the duty to respect patient auton-
autonomy assumes that patients are able to omy in some cases will include trying to help
draw upon all the resources necessary, deliberate patients achieve as much autonomy as possible
objectively, arrive at independent judgements in the circumstances, and this requires consid-
and communicate their decisions effectively. eration of the various dimensions that might be
Such a description does not fit the experience of undermining their autonomy.
many ill people who encounter a busy and One serious type of threat to patient auto-
complex health care system, consisting of over- nomy concerns the fact that the set of mean-
worked caregivers struggling to provide efficient ingful options available to patients is shaped by
but somewhat regimented care. Moreover, the the circumstances of each oneÕs social, political,
traditional interpretation treats all patients as economic and cultural situation; for example,
generic, or interchangeable. It ignores important patients without adequate health insurance will
differences among actual patients; each enters have far fewer accessible medical options than
the decision-making process from unique cir- those living within a well-supported healthcare
cumstances that may place important, but easily system. And patients who belong to minority
overlooked limits on their choices. In addition, it cultures may encounter health care providers
focuses too heavily on evaluating the compe- who are unwilling to allow the use of their
tency of the patient and not nearly enough on traditional healing practices. We believe the
examining the range and nature of the options received view of autonomy is mistaken insofar as
from which each patient must choose. it assumes that agents can step back from this
social web and engage in a process of rational
deliberation that is not importantly complicated
Relational autonomy
by the details of their particular social circum-
To meet some of these difficulties, we subscribe to stances.
an alternative conception of autonomy called Our relational approach is particularly con-
Ôrelational autonomyÕ. It identifies a broader cerned with questions of social justice. We think

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 A relational perspective on autonomy for older adults, S Sherwin and M Winsby 185

it necessary to consider the impact of patterns of nalize some of the social biases attached to their
inequality and prejudice on the options and group, they often experience a reduced sense of
opportunities available to each person. self-worth and self-trust;5 yet, self-trust is an
Although respect for patient autonomy helps to essential component of exercising autonomy.
ensure that efforts will be made to protect the Older adults, along with people living in poverty
rights and interests of even seriously disadvan- and members of racialized minorities, are con-
taged patients, it is not a sufficient response to stantly exposed to deeply entrenched stereotypes
structural inequalities. To promote greater that deny their competence to manage their own
autonomy, it is also necessary to recognize and lives well; some have a hard time believing there
address the ways in which oppressive structures is no truth to these biases. When agents experi-
can undermine the autonomy of many patients. ence diminished self-trust, they are less likely to
Within societies prone to discrimination against challenge the pervasive biases that structure the
older adults, this is an important dimension to options made available to them or to question
include in our reflections on obligations to older the system of rewards and punishments that
persons residing in nursing homes. encourage them to comply with dominant ste-
Relational theory rejects atomistic under- reotypes.
standings of the self and insists that we be When oppression structures the options
attentive to the ways in which membership in available to members of disadvantaged groups
socially salient groups affects agentsÕ experiences and unjustly limits the opportunities to express
throughout life. It makes clear that the relational autonomy, increasing a personÕs autonomy
self is encouraged and maintained within a cannot be achieved merely through better edu-
complex set of social relationships, and this set cation or increased competence. What is really
of relationships – both public and personal – will required is a change in the background social
be differently enabling. Members of oppressed conditions which conspire to perpetuate their
or stigmatized groups are more likely to be dis- oppression and thereby undermine their full
advantaged with respect to their degrees of autonomy. For agents to be autonomous, they
social mobility, income-earning potential and must be able to resist the options that help to
even their quality of health care.4 They fre- sustain their own oppression. To ensure that
quently face group-specific constraints on the conditions are such that the exercise of a rea-
types of choices available to them, and the sonably high degree of autonomy is possible, it is
consequences attached to resisting prevailing sometimes necessary to try to correct limitations
patterns of practice reflect widespread under- inherent in the background conditions of each
valuing of the group as a whole. It is common personÕs social location.
for members of oppressed groups to find that the We want to draw attention to one more dif-
options they are to choose amongst are skewed ference between relational autonomy and the
towards practices that sustain their oppression. more familiar traditional conception before
For example, women are encouraged to meet turning to the implications of a relational
demanding standards of youth and beauty to the approach to autonomy in clinical encounters
point that many face serious discrimination if involving older nursing home residents. Tradi-
they allow their hair to turn grey and their faces tional accounts of autonomy implicitly favour
to display wrinkles. Jurisdictions that still permit an ideal of independence and view dependence
mandatory retirement make it difficult for many or reliance on others as an impediment to
older adults to earn an income that will keep autonomy. Negative attitudes towards depen-
them from poverty. This serves to increase the dence are problematic for at least three reasons:
social isolation of many, and further reinforces (i) they ignore the important fact that we are all
stereotypes. interdependent and rely on one another in
A further complication has to do with the fact multiple ways, (ii) they serve to devalue efforts to
that when members of oppressed groups inter- care for others by denying the urgency and fre-

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186 A relational perspective on autonomy for older adults, S Sherwin and M Winsby

quency of such work, and (iii) they devalue and structure the options available to older
persons who are clearly highly dependent, such adults and the ways in which they may be
as children and people with serious disabilities.5 particularly vulnerable to reduced opportunities
Relational theory seeks to make explicit the for exercising autonomy.
reality of multiple layers of interdependence and Among the stereotypes associated with grow-
the importance of resisting tendencies to devalue ing old are loss of cognitive abilities like memory
people with special needs and those who care for and the ability to learn new skills, physical
them. The case of autonomy among older adults decline, unattractiveness and general uselessness.
who reside in nursing homes is particularly Many seniors struggle with family members and
challenging because many experience a real and health care providers to maintain their auton-
steady loss of both independence and autonomy, omy in health and other matters when well-
and the institutional requirements of nursing meaning others seek to exercise paternalism. In
homes make it difficult to fully address the broad the face of such systemic discrimination, it is
spectrum of their individual circumstances, particularly important to use a relational
while biases against older persons are pervasive autonomy lens that is sensitive to the dangers of
in many modern societies. distorting stereotypes. This lens helps to reveal
the frequency of unjustified paternalism towards
competent seniors and provides grounds for
Relational autonomy and ageing
developing strategies to protect the autonomy
We shall focus more narrowly now on one rights for vulnerable older patients.
particular group that is subject to systemic The task is complicated, however, by the fact
discrimination, namely older adults. Relational that there is some basis in truth for some of the
autonomy is explicitly concerned with protect- stereotypes. Generally, old age does carry it with
ing and promoting the autonomy of members it some deterioration in physical abilities and,
of oppressed groups, and, hence, it is a valuable for far too many elderly persons, it also involves
lens to use in our discussion. We believe that a significant decrease in cognitive capacities.
older adults (at least within mainstream North Older citizens are at far higher risk than others
American society) are victims of ageism, a of developing forms of dementia that undermine
particular form of oppression. Monique M. their competence, and, thereby, the degree of
Williams defines ageism as Ôprejudice towards, autonomy they can exercise.
stereotyping, or discrimination against persons Adapting to increased dependence after a long
solely on chronological age deemed to be life of relative independence is challenging both
‘‘old’’Õ.6 (P.443) Certainly, older persons are for older persons and for those who care for
frequently victims of pernicious stereotypes, them. These challenges are particularly acute for
negative attitudes, and outright abuse.6 They those who live in institutions, particularly nurs-
are often overlooked, if not actively excluded, ing homes – that is, residential facilities that
in the hiring market – until very recently, it was provide nursing and personal care to dependent
common to force people to retire at a desig- residents. There are many types of care aimed at
nated age, no matter what their state of health seniors unable to live independently. Some, such
and capacities. Furthermore, as Williams points as assisted living, community support, and home
out, prejudice with respect to age remains care are aimed at helping seniors to live in pri-
acceptable among young people. It finds vate homes. There are also several types of
expression in the media and in popular culture, facility-based residential options for seniors with
and it influences the way the young interact greater needs, including hospitals and nursing
with their elders.6 In a culture that glorifies homes – which provide round-the-clock support
youth, ageing is often treated with fear and and professional nursing services.7 Nursing
aversion. Relational autonomy directs us to homes accept residents who have lost significant
consider the ways in which such biases limit physical and ⁄ or cognitive function. Hence, the

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 A relational perspective on autonomy for older adults, S Sherwin and M Winsby 187

institutions are designed to try to compensate dementia are limited in their capacity to make
for lost capacities; this focus can leave residents choices that are in their best interests. For the
vulnerable to mistaken presumptions about their many nursing home residents who are seriously
individual level of competence and create little compromised in their cognitive capacities,
space for attending to remaining levels of paternalistic treatment is not only warranted; it
autonomy. These threats to their autonomy is often a necessary part of their overall care.
occur not only in the realm of medical decision Sometimes, caregivers must insist on matters of
making but also in other aspects of their daily hygiene, medication, or nutrition despite vigor-
care. ous refusal on the part of confused residents.
The greater acceptance of institutionalization Indeed, in many cases, there is a more serious
for older adults which has occurred over the last risk of neglect of the residentsÕ needs and a
century has exacerbated our societal tendency to failure of paternalistic care than of someone
view them as Ômajor social problems, rather than overruling patientsÕ expressed wishes. ÔRespect
as people who can provide a sense of wholeness for patient autonomyÕ, when patients lack the
or wisdomÕ.8 (P.191) This pattern reinforces capacity for consent, should never serve as an
rather than challenges the pervasive ageism that excuse for failure to identify and respond to the
plagues the care seniors receive.8 Those who needs of a patient who cannot make explicit
enter nursing homes inevitably face a significant requests. The difficulty, then, is to find an
reduction in the range of options available to appropriate balance that avoids deployment of
them by virtue of the nature of institutionalized either a generalized deferral or a catch-all
living itself.9,10 Many nursing homes adhere to paternalism when responding to residentsÕ
an institutional model of care, which focuses expressed wishes.
first and foremost on task completion – such as Unfortunately, many nursing homes are not
dressing, bathing, feeding – and documenta- well structured to manage this delicate balance.
tion7,11 Emphasis on the physical care of nursing Many are modelled on medical facilities and
home residents in a regimented, task-oriented presume that autonomy is relevant only if it
facility fosters a structure that privileges effi- meets idealized standards of informed consent.
ciency over resident choice. The limited options Cathy Butterworth (2005) discusses this and
with respect to personal space, for example, are other difficulties with consent on the part of
particularly salient.12 Often, only semi-private older persons in nursing homes. She points out
rooms are available to residents, where they are that the issue of consent in the nursing home
paired with a stranger without their explicit context is one which has been scarcely resear-
consent. Private rooms may be available, but ched, and differs from consent in the medical
only at additional cost to the resident.13 It seems context mainly because, as we have suggested,
that in many nursing homes, those who enter the process is ongoing and represents a Ôstage in
surrender the opportunity to maintain privacy the continuum of involvementÕ between care
or personal control over many ordinary matters; giver and resident. She argues that consent
residents are treated as having issued blanket cannot be viewed as a Ôone-offÕ event, or even
consent to close physical contact with nursing episodically. Instead, if it is to be meaningful,
professionals and other care workers. Daily consent in the nursing home must be viewed as
activities like meals, social interaction, and Ôone aspect in a process of including service users
bathing, are often structured in ways that leave in decisions about their careÕ.14 (P.40) Consent
little space for residents to make choices. forms are not in and of themselves adequate to
Although it is important to respect autonomy issue consent to the various types of care
for seniors who retain competence, not every administered in the nursing home setting.14
older adult is able or willing to take on respon- When a single facility is responsible for deliver-
sibility for important decision making.14 ing medical and nursing care, along with the
Patients who suffer from even moderate necessities of daily living (help with feeding,

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188 A relational perspective on autonomy for older adults, S Sherwin and M Winsby

dressing, bathing, etc.), the norms of medical assume negative characterizations of ageing and
decision making can blend unnoticed into the dependency, and experience some decline in
other realms of life for residents. their own capacities, the result can be a dimin-
In addition, the rhythms of running the ished sense of self-worth and self-trust. The
institution and the practices that can become belief that one is not competent, or must rely
normalized create an environment where new heavily on others to make decisions on oneÕs
residents may find that their opportunities to behalf, can become self-fulfilling.
exercise autonomy become very limited very Against this backdrop of real and presumed
quickly, and often, more severely than their limits to decision-making ability among older
current abilities demand. Seniors enter these nursing home residents, it is particularly urgent
facilities because they have become unable to to ensure that staff members are attentive to the
care for themselves, but the type and degree of dangers of pervasive stereotypes. They must be
impairment can vary widely. While many suffer vigilant in their commitment to be responsive to
dementia, others do not; even those diagnosed the desires of residents who wish to exercise a
with a disease such as AlzheimerÕs disease that degree of autonomy and who maintain some
results in dementia may enter care at a time capacity for doing so. For example, to ensure
when they are still capable of making at least respect for the ways in which residents want to
some types of choices for themselves. The fact live the rest of their lives, staff should provide
that they are dependent on others for assistance opportunities for residents to engage their deci-
with the tasks of day-to-day living, as well as sion-making skills where possible. Unfortu-
nursing care and medical treatment, and that nately, many nursing homes are designed to
they may have difficulty making complex deci- address physical needs without being sufficiently
sions runs the risk of being interpreted to mean attentive to social dimensions. A focus on
that they are unable to make any types of deci- medical needs, together with an assumption that
sions for themselves. However, expanding resi- loss of independence means loss of all mean-
dentsÕ roles in decision making can be a very ingful degrees of autonomy, results in limited
difficult practical issue, as decisions about opportunities for self expression. Such tenden-
prescriptions, for example – one of the most cies can be resisted if we adopt a relational
common medical interventions faced by nursing autonomy lens that is sensitive to the harms of
home residents – can have significant repercus- pervasive ageism and that appreciates the
sions for patientsÕ wellbeing. Hughes and Gol- importance of fostering autonomy by creating
die15 examine the degree to which the residents opportunities to promote and exercise it. If we
in several Northern Ireland nursing homes par- take a broader view of the nature of autonomy,
ticipated in prescription decisions. For the most we are more likely to reflect on the possibility of
part, they found, residents deferred to prescrip- expanding opportunities for choice and
tion decisions made for them. While health care improving the types of options available.
workers agreed that more resident involvement Nursing homes are charged with the respon-
in these decisions would lead to greater auton- sibility for delivering the necessities of life for a
omy among the elderly residents, they also held wide range of patients with complex conditions
that ÔcontrolÕ of the prescription ⁄ administering and each facility must meet regulated norms for
process within the nursing home would be the services they provide. They must provide
compromised. The stereotypes of declining care within a budget that is often far less than
mental faculties that plague all seniors are par- what ideal care demands. Typically, they are
ticularly strong with respect to those living in short staffed and rely heavily on minimally
nursing homes. trained workers. Heavy workloads, fatigue, lack
Moreover, some seniors internalize the beliefs of proper equipment and inadequate training are
and attitudes towards old age that are pervasive not uncommon, and can conspire to render the
within the larger culture. When older persons environment unsafe.13 In the face of such pres-

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 A relational perspective on autonomy for older adults, S Sherwin and M Winsby 189

sures, it is understandable that the institutional foster degrees of relational autonomy even when
model of care, which is task-oriented and regi- more traditional versions of autonomy are no
mented toward efficiency, has remained preva- longer available.17
lent among nursing facilities. Circumstances We recognize that demands to attend to
often make it difficult to customize arrange- patientsÕ autonomy present very real difficulties
ments in ways that encourage each resident to in the clinical encounter of nursing home care.
maintain and exercise as much autonomy as Such demands are especially challenging when
he ⁄ she can. autonomy among the elderly is often elusive, and
Fortunately, there are alternative models the barriers to autonomous choice within nursing
available that offer ways of breaking this homes are many and complex. Less institutional
destructive cycle. ÔResident centeredÕ care mod- models of care that are more sensitive to the
els, such as Eden Alternative, and Ôrelationship social facts of nursing home residents probably
centeredÕ models such as My Home Life in the require resources and staffing ratios that are
United Kingdom move away from the tradi- difficult under current funding conditions.
tional medicalized, institutional method of care. Nonetheless, we believe that the virtues of
They seek to open communication among all adopting a relational approach to enhancing the
levels of staff and to set Ôa standard of how to autonomy of older residents in nursing homes
treat residents by treating staff with respect and outweigh these difficulties. As far as possible,
dignityÕ.16 (P.189) They actively try to foster nursing homes should try to assist residents in
communities within nursing homes where elderly maintaining control over matters of importance
residents Ôexperience dignity and respect, have a to them by fostering a facility culture marked by
choice in everyday activities, have connections increased resident options and a care model that
with the outside world by frequent interactions prioritizes the social well-being of elderly resi-
with the external community and develop dents over completion of care regimens.
meaningful relationships with other living things A relational autonomy lens helps us to appre-
(including plants, animals, and humans)Õ.16 Such ciate the importance of making nursing homes
respect-oriented care models may provide useful responsive to the impact of the cultural devaluing
starting points for the redesign of programmes, of old age on seniorsÕ self-image and self-trust and
which will be more sensitive to the autonomy the orientation of their caregivers. It sheds light
interests of residents.16 on the barriers to autonomous choice that stem
from social, as well as cognitive, limitations.
Through such reflection and action, we seek to
Conclusion
support efforts to alter the structures common to
To truly attend to the needs and interests of frail many nursing homes and encourage opportuni-
older persons who require the care associated ties to promote a degree of autonomy for residents
with residency in nursing homes, we need to wherever possible. A relational framework that is
change the conceptual framework within which attentive to the role of biases and the importance
many facilities function and be more attentive to of relationships can help facilitate required insti-
the need to correct the damage of oppressive tutional transformations. It reminds us that the
ageism. A relational autonomy approach sug- responsibility for promoting and protecting the
gests that the problem does not lie primarily with autonomy of even the most vulnerable citizens
specific caregivers or institutional managers, but extends beyond the duties of institutional care-
rather with the cultural space occupied by nursing givers and is shared by all of society.
homes for older citizens. We need to challenge
the multiple ways by which most parties begin
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