1. Paternalism and Patient Autonomy
Vaughn, Chapter 3

2. Autonomy
What Autonomy is: Autonomy is a person’s rational capacity for self-governance Its value is expressed in the Autonomy Principle: Autonomous persons should be allowed to exercise their capacity for self-governance –Vaughn, p.51

3. Paternalism, Weak and Strong
Paternalism = benevolent action irrespective of or even contrary to the wishes of the beneficiary. The term paternalism comes from Latin, pater, meaning father … fatherly. As such, Paternalism is always a violation of patient autonomy, though perhaps justified, depending on circumstances.
Click the image above (when in Slide Show mode) for a youTube video …. see short scene of Paternalism in action beginning at 0:59.
“I won’t let you!” lol!

4. Paternalism, Weak and Strong
What paternalism is not:
Stopping someone from harming others (sometimes called “delegated police authority”)
Overriding a patient’s wishes in order to benefit the hospital, doctor, nurse, etc.
Overriding the patient’s wishes when they conflict with the health care provider’s values

5. Paternalism, Weak and Strong
Strong Paternalism (sometimes called extended paternalism) = overriding of a competent patient’s wishes Weak Paternalism (sometimes called cooperative paternalism) = overriding of an incompetent or doubtfully competent patient’s wishes (Vaughn differs a bit, p.52, paragraph 2; prefer ppt definition)

6. Paternalism, Weak and Strong
Strong Paternalism = overriding of a competent patient’s wishes
Is Strong Paternalism ever justified?
For government:
To protect the rights of others
To protect an overriding state interest (is this the basis for prohibiting suicide?)
Are these technically ‘paternalistic’?

7. Paternalism, Weak and Strong
The government, however, has not authorized health care providers to use strong paternalism …
-Garrett et al., p 41, paragraph 2 (Book is cited on slide 17; you do not need to retrieve this book)
Garrett provides …
inability to know another’s values and
the possibility of multiple acceptable choices
as reasons to reject strong paternalism.

8. Paternalism, Weak and Strong
Weak Paternalism = overriding an incompetent or doubtfully competent patient’s wishes: Courts have accepted weak paternalist excuses when overriding the patient’s wishes is required to relieve the patient’s serious pain or suffering Weak paternalism is also mitigated if exercised to gain informed consent. Garrett calls such “in the service of autonomy.” Vaughn says as much p.52

9. Paternalism, Weak and Strong
Restraints: restraints are justified on weak paternalistic grounds when patients are confused or disoriented, posing a danger to themselves. Their use should include safeguards:
Periodic patient visits
Approval of supervisors and or physicians
“Written justification”

10. Paternalism, Weak and Strong
Garrett notes trepidation regarding paternalism on p 42: “we insist that there is no general authorization for even weak paternalism. Each case needs to be studied, and exceptions should be made carefully.”

11. Therapeutic Privilege
The law has recognized paternalism under the name Therapeutic Privilege. Therapeutic Privilege = the privilege of withholding information from the patient when the physician believes that the disclosure will have an adverse effect on the patient’s condition or health.

12. Therapeutic Privilege
3 conditions guide the use of therapeutic privilege:
Its use must not be based on generalities, but on the actual circumstances of the particular patient
The physician must have a founded belief, based on intimate knowledge of the patient, that full disclosure will have a significant adverse effect on the patient
Reasonable discretion must be used in the manner and extent of the disclosure

13. Therapeutic Privilege
Garrett dislikes this legal device; notes 2 problems with it:
Research fails to confirm full disclosure adversely effects patient condition or health
It is a denial of patient autonomy

14. Futile Treatment
Vaughn notes that sometimes physicians and patients disagree in reverse … the patient wants treatment and the physician refuses.
Can happen over …
amputation fetish
worthless or unproven drugs, but more often,
Sanctity of life v. Futility

15. Applying Major Theories
Look at pp 56, 57.
Utilitarians will be tempted to use Paternalism. Why?
How can J.S. Mill think it’s okay to let someone ruin their life (supposing they choose to die or shorten their life by refusing treatment)?
How can Kantian physicians allow someone under their care to commit suicide by refusing treatment? Isn’t suicide always wrong?

16. Applying Major Theories
On page 57, the book says Natural Law theory is more paternalistic than Kantian ethics, but doesn’t say why. Why should it be? What is the doctrine of double effect? Read the six examples under “Applications” here: How does the doctrine apply in the context of Paternalism vs. Autonomy?
Consider trolley car scenario using notion of double-effect, ending at 9:36.
(Click image in Slide Show mode for youTube video)

17. Applying Major Theories
What would a Virtue Theorist think … or, how would Aristotle go about deciding whether Paternalism is always, sometimes, or never justified?

18. References
Vaughn, L. (2010). Bioethics Garrett, T. M., Baillie, H. W., Garrett, R. M. (2001). Health Care Ethics (4th Edition)

19. Cases for Evaluation
Case 1 – Prayer, Medicine, and a Child’s Death Do you agree with the court’s decision to reverse the manslaughter conviction? Should parents have the right to refuse medical treatment for their children on religious grounds? What moral principle would support your judgment? See the rest on page 60, Vaughn.

20. Cases for Evaluation Case 2 – State Paternalism and a Pregnant Woman
Do you agree with the Supreme Court’s decision? Why or why not?
Should the state force pregnant women to behave in certain ways while carrying a fetus?
Is a pregnant woman guilty of “fetal abuse” if she refuses to eat properly?
Drinks any amount of alcohol?
Forgoes prenatal care?

21. Cases for Evaluation
Case 3 – Medical Futility Do you agree with the hospital’s decision to withdraw care? Do you agree with the child’s parents? Do you accept the sanctity of life view, or think quality of life should determine what to do in cases like this? How do you justify your view?