Autonomy

1
Autonomy Paternalism

• Andrew Latus
• Ethics/Humanities/Health Law
• Nov. 14, 2002

2
Objective

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

3
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
  patients best interests not to know certain
  information (Doing Right, 79)

4
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
  best interest.
• Generally, paternalism in medicine is viewed as
  being a bad thing.
• Question Whats wrong with paternalism?

5
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

6
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

7
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 persons
  ultimate decision, but would think it wrong not
  to at least try to change the 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
  seems appropriate.

8
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 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.

9
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
  persons 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.

10
The Rule of Justified PaternalismStolen from
Dr. Daryl Pullman
The amount of paternalistic intervention
justified or required, is inversely proportional
to the amount of autonomy present
AUTONOMY
PATERNALISM
11
Autonomy Patients

• The usual situations in which doctors encounter
  patients are situations that threaten a patients
  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?

12
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

13
The Doctor-Patient Relationship

• 2. Technical
• Model Contractor-client
• Doctor presents options. Patient decides.
• Maximum autonomy for patient

14
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.

15
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.