Learning from Elders about Autonomy, Meaningfulness, and Relationships
Round 1
Reviewer 1 Report
This commentary aims to call for a more concrete and realistic understanding of autonomy and meaningfulness that can be applied to actual daily life experiences of elders, especially those living with diminished capacity. The authors first give a well-conceived critique of the classical liberal conception of autonomy, human agency, independence, and meaning making. They accurately point out that this classical liberal view of autonomy is irrelevant when we try to understand autonomy and meaningfulness in human lives “in the context of frailty and concomitant dependence resulting from serious illness and/or old age.” Rather, the authors persuasively argue that the liberal view perpetuates ageism and misguides us to think that people with disabilities will have limited or no autonomy. On the other hand, from spiritual and developmental perspectives, the authors logically contend that the kind of autonomy constructed or imagined by the classical liberal view has never existed, as human beings, from the day they were born to the day they died, rely on their relationships and interactions with others to survive, thrive, and make sense of their lives. In other words, dependence, or rather, interdependence is the reality of human existence. Therefore, the authors appeal to researchers to move away from the liberal view and to broaden or even transform our understanding of how people actually experience and exercise autonomy and meaning making via important human relationships, especially when they are in a situation where they need more than usual to rely on others’ support to achieve their autonomy.
The authors have developed their critique and arguments based on the findings of relevant literature and studies. Although the classical liberal view of autonomy, independence, and meaningfulness has long been criticized, the authors do a good job bringing this much needed discussion to the research and service of elders with diminished capacity in the context of long-term care as a relatively new attempt, by starting to reexamine and better conceptualize autonomy and meaningfulness. This commentary is also written in a clear and organized manner. One area for improvement, however, is that the section of direction for further research could be expanded on. It would be helpful, for instance, if specific research questions could be offered as suggestions for future research. Possible implications for serving elders could also be explored.
Author Response
In response to reviewer comments, specific research questions were suggested for further empirical research. We included details on our future research project in the relevant section of the paper as well as its implications for serving elders (insights for improving autonomy-supportive healthcare for frail elders and potential resources for long-term care and hospice palliative care organizations).
Reviewer 2 Report
It is valuable to review psychologically autonomy and meaningfulness in the life span of having to rely on others due to aging or illness in senescence. As Erikson’s psychosocial developmental theory emphasized, old age is a time to integrate the meaning of life, so it is significant to conceptualize the meaningfulness of frail and dependent elderers’ situations.
I think this manuscript is a well organized commentary that has discussed a special topic. Those things are as follows.
1. There are some parts where the paragraph is too long to read. (eg. Line 534-579)
2. It is necessary to check whether any of the parts in footnotes improve readability when described in the text of the manuscript.
3. I think it would be good to improve the quality of the manuscript by comprehensively considering other aspects and viewpoints of the statements presented.
4. It is necessary to present the direction for further empirical researches in more detail. For example, there are many subjective aspects of autonomy, so it is necessary to empirically explore the relationship between perceived autonomy and mental health or well-being of the frail and dependent elderly. And, because of the nature of this journal, it's better to suggest not only the psychological variables that will be included in those studies, but also the religious variables.
5. Please provide references consistently according to the reference style in this journal.
Author Response
- There are some parts where the paragraph is too long to read. (eg. Line 534-579)
Response: Upon review, paragraphs longer in length were broken down into several paragraphs for readability. (E.g., the paragraph mentioned by the reviewer on pages 8-9, directions for further research section on page 18).
- It is necessary to check whether any of the parts in footnotes improve readability when described in the text of the manuscript.
Response: Footnotes were carefully reviewed for relevance and footnotes # 44, 65 and 71 were removed to improve conciseness and readability. Footnotes # 8, 13, 18, 28 and 66 from the original submission were moved into the text of the manuscript to improve flow.
- I think it would be good to improve the quality of the manuscript by comprehensively considering other aspects and viewpoints of the statements presented.
Response: The first section of the paper is formatted to carefully dissect the liberal view of autonomy before presenting the perspective of Agich’s relational autonomy. This allows us to consider different perspectives on autonomy and discuss which conceptualization better fits the reality for PWD and frail elders. In the second section on meaning-making, we look at different ideologies on what makes life meaningful (e.g., Kant, Max Weber, MacKinlay, Chochinov). These represent the most important objections to the alternative feminist, relational perspective we discuss in this paper.
- It is necessary to present the direction for further empirical researches in more detail. For example, there are many subjective aspects of autonomy, so it is necessary to empirically explore the relationship between perceived autonomy and mental health or well-being of the frail and dependent elderly. And, because of the nature of this journal, it's better to suggest not only the psychological variables that will be included in those studies, but also the religious variables.
Response: More details on the authors’ future research project is provided, including the project direction for empirical research and implications for PWD, their carers and long-term and hospice palliative care organizations. A potential question for further research was also added suggesting the need to explore the role of spirituality and/or religion and mental health on the experience of autonomy and meaningfulness.
- Please provide references consistently according to the reference style in this journal.
Response: Referencing throughout the manuscript was reviewed and revised to ensure consistency with MDPI’s suggested referencing style.
