PATERNALISM AND ITS IMPLICATION IN MEDICAL ETHICS

INTRODUCTION

The field called applied ethics has so many sub branches under it, for instance, under applied ethics we have the field called business ethics, medical ethics, legal ethics, journalistic ethics among many others. However, various branches of applied ethics or better still various profession have their own language and axioms guiding them. Consequently, this leads us to the term or concept known as paternalism. Paternalism is one that arises in many different areas of our personal and public life. As such, it is an important realm of applied ethics. But it also raises certain theoretical issues. Perhaps the most important is: what powers it is legitimate for a state, operating both coercively and in terms of incentives, to possess. It also raises questions about the proper ways in which individuals, either in an institutional or purely personal setting, should relate to one another. How should we think about individual autonomy and its limits? What is it to respect the personhood of others? What is the trade-off, if any, between regard for the welfare of another and respect for their right to make their own decisions?

WHAT PATERNALISM IS

Paternalism is the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm. The issue of paternalism arises with respect to restrictions by the law such as anti-drug legislation, the compulsory wearing of seatbelts, and in medical contexts by the withholding of relevant information concerning a patient's condition by physicians. At the theoretical level it raises questions of how persons should be treated when they are less than fully rational.

The analysis of paternalism involves at least the following elements. It involves some kind of limitation on the freedom or autonomy of some agent and it does so for a particular class of reasons. As with many other concepts used in normative debate determining the exact boundaries of the concept is a contested issue.

And as often is the case the first question is whether the concept itself is normative or descriptive. Is application of the concept a matter for empirical determination, so that if two people disagree about the application to a particular case they are disagreeing about some matter of fact or of definition? Or does their disagreement reflect different views about the legitimacy of the application in question?

While it is clear that for some to characterize a policy as paternalistic is to condemn or criticize it, which does not establish that the term itself is an evaluative one. As a matter of methodology it is preferable to see if some concept can be defined in non-normative terms and only if that fails to capture the relevant phenomena to accept a normative definition.

Examples of paternalism include laws requiring the use of motorcycle helmets, a parent forbidding their children to engage in dangerous activities, and a psychiatrist confiscating sharp objects from someone who is suicidally depressed.

Thus, in stranford encyclopedia of philosophy, we are introduced to the concept of paternalism by the following conditions or illustration; an analysis of X acts paternalistically towards Y by doing (omitting) Z:

1. Z (or its omission) interferes with the liberty or autonomy of Y.
2. X does so without the consent of Y.
3. X does so just because Z will improve the welfare of Y (where this includes preventing his welfare from diminishing), or in some way promote the interests, values, or good of Y.

Condition one is the trickiest to capture. Clear cases include threatening bodily compulsion, lying, withholding information that the person has a right to have, or imposing requirements or conditions. But what about the following case? A father, skeptical about the financial acumen of a child, instead of bequeathing the money directly, gives it to another child with instructions to use it in the best interests of the first child. The first child has no legal claim on the inheritance. There does not seem to be an interference with the child's liberty nor on most conceptions the child's autonomy.

Or consider the case of a wife who hides her sleeping pills so that her potentially suicidal husband cannot use them. Her act may satisfy the second and third conditions but what about the first? Does her action limit the liberty or autonomy of her husband?

The second condition is supposed to be read as distinct from acting against the consent of an agent. The agent may neither consent nor not consent. He may, for example, be unaware of what is being done to him. There is also the distinct issue of whether one acts not knowing about the consent of the person in question. Suppose the person in fact consents but this is not known to the paternaliser.

The third condition also can be complicated. There may be more than one reason for interfering with Y. In addition to concern for the welfare of Y there may be concern for how Y's actions may affect third-parties. Is the “just for” condition too strong? Or what about the case where a legislature passes a legal rule for paternalistic reasons but there are sufficient non-paternalistic reasons to justify passage of the rule?

If, in order to decide on any of the above issues, one must decide a normative issue, e.g. does someone have a right to some information, then the concept is not purely descriptive. Ultimately the question of how to refine the conditions, and what conditions to use, is a matter for philosophical judgment. The term “paternalism” as used in ordinary contexts may be too amorphous for thinking about particular normative issues. One should decide upon an analysis based on a hypothesis of what will be most useful for thinking about a particular range of problems. One might adopt one analysis in the context of doctors and patients and another in the context of whether the state should ban unhealthy foods.

THE JUSTIFICATION OF PATERNALISM IN MEDICAL ETHICS

As we have seen the analysis of paternalism seems to cut both ways. It is an interference with liberty which might be thought to place the burden of proof on the paternalist. It is an act intended to produce good for the agent which might be thought to place the burden of proof on those who object to paternalism. It might be thought, as Mill did, that the burden of proof is different depending on who is being treated paternalistically. If it is a child then the assumption is that, other things being equal, the burden of proof is on those who resist paternalism. If it is an adult of sound mind the presumption is reversed.

Suppose we start from the presumption that paternalism is wrong. The question becomes under what, if any, circumstances, can the presumption be overcome? The possible answers are “under no circumstances”, “under some circumstances”, and “under any circumstances”

The last seems very implausible. Essentially it is the view that the fact that an act is (intended to be) beneficial for a person, and does not affect or violate the interests of others, settles the question of whether it may be done. Only a view which ignores the means by which good is promoted, and the ethical status of such means, can hold this. Any sensible view has to distinguish between good done to agents at their request or with their consent, and good thrust upon them against their will.

So the normative options seem to be just two. Either we are never permitted to do good for others against their wishes, and in ways which limit their liberty, or we are permitted to do so.

Why might one think that at least the state may never do so? One might think so because of various beliefs about the impossibility of in fact doing good for people against their will or because one thinks that although possible to do good it is in fact inconsistent with some normative standard which ought to prevail.

With respect to the impossibility question one might believe either that it is not possible to do any good by acting paternalistically or that although it is possible to do some good the process will (almost) always produce bad which outweigh the good.

If one thought that almost)always more harm than good is done by the state when it acts paternalistically this raises the question of whether we can distinguish the conditions in which (rarely) more good than harm is done and build that into our guidelines. If this is possible, and so distinguishing does not create further harms which outweigh the good produced, and we think, the only issue is good promotion we should sometimes be paternalists. If it is impossible to distinguish the “good” from the “bad” cases then, at least if we are rule consequentialists, we ought not to have such a rule; and we ought not to try and make the distinctions on a case by case basis.

But one might believe that the question of whether more good than harm is produced is not simply an empirical one. It depends on our understanding of the good of persons. If the good simply included items such as longer life, greater health, more income, or less depression, then it makes it look like an empirical issue. But if we conceive of the good of individuals as including items such as being respected as an independent agent, having a right to make decisions for oneself, or having one's autonomy not infringed, then the issue of whether the agent is better off after being `subjected to paternalism is partly a normative matter. One might believe that one cannot make people better off by infringing on their autonomy in the same way that some people believe one cannot make a person better off by putting them in a Nozickian experience machine.

Kantian views are frequently absolutistic in their objections to paternalism. On these views we must always respect the rational agency of other persons. To deny an adult the right to make their own decisions, however mistaken from some standpoint they are, is to treat them as simply means to their own good, rather than as ends in themselves. In a way anti-paternalism is already incorporated into Kantian theories by their prohibition against lying and forces—the main instruments of paternalistic interference. Since these instrumentalities are already denied even to prevent individuals from harming others, they will certainly be forbidden to prevent them from harming themselves. Of course, one may object to the former absolutism while accepting the latter.

If one believes that sometimes paternalism is justifiable one may do so for various kinds of theoretical reasons. The broadest is simply consequentialist, i.e. more good than harm is produced. A narrower justification is that sometimes the individuals (long-run) autonomy is advanced by restricting his autonomy (short-run). So one might prevent people from taking mind-destroying drugs on the grounds that allowing them to do so destroy their autonomy and preventing them from doing so preserves it. This is essentially Mill's argument against allowing people to contract into slavery. Note that if the theory of the good associated with a particular consequentialism is broad enough, i.e., includes autonomy as one of the goods, it can be equivalent to the autonomy theory (assuming that the structure of the autonomy view is a maximizing one).

A different theoretical basis is (moral) contractualism. On this view if there are cases of justified paternalism they are justified on the basis that we (all of us) would agree to such interference, given suitable knowledge and suitable motivation. So, for instance, it might be argued that since we know we are subject to depression we all would agree, at least, to short-term anti-suicide interventions, to determine whether we are suffering from such a condition, and to attempt to cure it. More generally, we might accept what Feinberg called “soft paternalism.” This is the view that when we are not acting fully voluntarily it is permissible to intervene to provide information, or to point out defects in our rationality, but that if we then do make a voluntary choice it must be respected. Or we might agree to being forced to wear seat-belts knowing our disposition to discount future benefits for present ones. The justification here is neither consequentialist nor based simply on the preservation of autonomy. Rather either kind of consideration may be taken into account, as well as others, in determining what we would reasonably agree to.

Conclusively, it is pertinent to note that paternalism as a concept greatly influences medical ethics as it affects the autonomy of patients and most times could lead to non-benevolence which is doing harm to others. From the above however, we can see various reasons that some medical practitioners will seldom give to carry out the act of paternalism.

REFERENCES:

‘Ethics’; Encyclopaedia Britannica

‘Medical Ethics and Applied Ethics’ in Stanford Encyclopaedia of philosophy

Applied Ethics; Perspectives from Asia and Beyond, Edited by Kohji Ishihara and Shunzo Majima.

Copy right: Richard Oluseye Anthony (Department of Philosophy, University of Ibadan, Nigeria.)