class12autonomy&paternalism

7/31/2019 Class12Autonomy&Paternalism

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Autonomy & PaternalismAndrew Latus

Ethics/Humanities/Health Law

Nov. 14, 2002


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Objective

To connect some of the ideas about

autonomy, beneficence, and consent that havebeen raised over the course of the term


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Therapeutic Privilege

In 1961, a study revealed that 88% of doctors

routinely would not tell terminally ill cancerpatients that they had cancer.

Therapeutic Privilege: When a doctor decides

for a seemingly capable patient that it is in thepatients best interests not to know certaininformation (Doing Right, 79)


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Paternalism To treat someone paternalistically is to treat the

person in a way that ignores or discounts his/her

wishes but aims at promoting the persons bestinterest.

Generally, paternalism in medicine is viewed as

being a bad thing.

Question: Whats wrong with paternalism?


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The Trouble with Paternalism Cases of paternalism are cases in which the

principles of beneficence/non-maleficence win afight with the principle of autonomy.

But respecting patient autonomy is widely seen asthe most important element in the doctor-patientrelationship.

Therefore, paternalism is a bad thing

or so the story goes


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Justifiable Paternalism? In both medical and non-medical contexts, to say

someone is acting paternalistically is to generally to

say something bad about that persons actions.

But there are occasions when paternalistic behaviour

is appropriate or even required

Parenting (Parentalism)

Incompetent Friends/Relatives


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Hard Cases Some of the most difficult cases concern circumstances where

we are confident that a competent friend or family member isgoing to make a bad decision

Here, we typically cannot control the persons ultimatedecision, but would think it wrong not to at least try to changethe persons mind.

I cant let you drop out of med school/go out with him/eat that

week old pork chop.

In these hard cases, some degree of paternalism seemsappropriate.


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The Myth of Perfect Autonomy Why is it morally okay to attempt to override your

friends/family members original intention in some cases?

Because, despite what philosophers might say about theimportance of autonomy, we are rarely, if ever, whollyrational self-rulers

A General Rule of Thumb: The further a person is, in aparticular situation, from being a rational self-ruler, the morepaternalistic behaviour is morally appropriate.


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Autonomy & Paternalism Our typical ways of thinking about

capacity/competence treat it as an on-off notion.

We set a legal line as a cut-off for taking a personsdesires as authoritative.

This is a useful legal device, but it hides the morally

important fact that capacity comes in degrees.Keeping this in mind is crucial if we want tounderstand the proper relationship betweenautonomy and paternalism.


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The Rule of Justified Paternalism**Stolen from Dr. Daryl Pullman

AUTONOMY

PATERNALISM

The amount of paternalistic

intervention justified or required, is

inversely proportional to the amount of

autonomy present


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Autonomy & Patients

The usual situations in which doctors encounterpatients are situations that threaten a patients abilityto function as a rational self-ruler.

Lack of understanding

Fear

Sickness

What does this tell us about the place of paternalismin the doctor-patient relationship?


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The Doctor-Patient Relationship

Which model of the doctor-patient

relationship is most appropriate?

1. Pure Paternalism

Model = Adult-Child (Hippocrates' view?) Doctor as expert

Focus is on care, but not autonomy


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2. Technical

Model = Contractor-client

Doctor presents options. Patient decides.

Maximum autonomy for patient


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3. Friendship

Charles Fried - doctors are "limited, special-purposefriends"

The doctor takes on the interests of the patient

Leaves room for both paternalism and autonomy and for

varying degrees of both in particular cases A friend will sometimes try to talk you into doing

something 'for your own good' even if that's not what yousay you want.


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The Moral

The huge stress placed on patient autonomy may go too far.

Autonomy is important, but paternalism has got too much bad

press.

Legally, the stress on autonomy makes sense, but we should not let itoversimplify the moral situation.

Corollary: the balance between paternalism & autonomy maybe better recognized in practice than in theory.

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