Autonomy & Paternalism Andrew Latus Ethics/Humanities/Health Law Nov. 14, 2002

Objective  To connect some of the ideas about autonomy, beneficence, and consent that have been raised over the course of the term

‘Therapeutic Privilege’  In 1961, a study revealed that 88% of doctors routinely would not tell terminally ill cancer patients that they had cancer. Therapeutic Privilege: “When a doctor decides for a seemingly capable patient that it is in the patient’s best interests not to know certain information…” (Doing Right, 79)

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 person’s best interest.  Generally, paternalism in medicine is viewed as being a bad thing.  Question: What’s wrong with paternalism?

The Trouble with Paternalism  Cases of paternalism are cases in which the principles of beneficence/non-maleficence win a fight with the principle of autonomy.  But respecting patient autonomy is widely seen as the most important element in the doctor-patient relationship.  Therefore, paternalism is a bad thing  or so the story goes…

Justifiable Paternalism?  In both medical and non-medical contexts, to say someone is acting paternalistically is to generally to say something bad about that person’s actions.  But there are occasions when paternalistic behaviour is appropriate or even required Parenting (‘Parentalism’) Incompetent Friends/Relatives

Hard Cases  Some of the most difficult cases concern circumstances where we are confident that a competent friend or family member is going to make a bad decision  Here, we typically cannot control the person’s ultimate decision, but would think it wrong not to at least try to change the person’s mind. ‘I can’t 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 seems appropriate.

‘The Myth of Perfect Autonomy’  Why is it morally okay to attempt to override your friend’s/family member’s original intention in some cases?  Because, despite what philosophers might say about the importance of autonomy, we are rarely, if ever, wholly rational ‘self-rulers’  A General Rule of Thumb: The further a person is, in a particular situation, from being a rational self-ruler, the more paternalistic behaviour is morally appropriate.

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 person’s desires 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 to understand the proper relationship between autonomy and paternalism.

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”

Autonomy & Patients  The usual situations in which doctors encounter patients are situations that threaten a patient’s ability to function as a rational self-ruler. Lack of understanding Fear Sickness  What does this tell us about the place of paternalism in the doctor-patient relationship?

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

The Doctor-Patient Relationship  2. Technical Model = Contractor-client Doctor presents options. Patient decides. Maximum autonomy for patient

The Doctor-Patient Relationship  3. Friendship Charles Fried - doctors are "limited, special-purpose friends" 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 you say you want.

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 it oversimplify the moral situation.  Corollary: the balance between paternalism & autonomy may be better recognized in practice than in theory.