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[Apr. 22nd, 2008|09:21 pm] |
Paternalism in Medical Practice
Paternalism, in the context of medicine and healthcare, describes a patient-doctor relationship where decisions are made independent of the patient’s beliefs and values, dictated with little respect for patient autonomy. It is justified by a claim that patients would be better off following the judgment of doctors (Healthcare ethics: Paternalism, 2007). Paternalism is ethically problematic because it puts into conflict two important values: autonomy – which is the right of individuals in making their own decisions, and beneficence – the importance of protecting others and doing what is best for them (Andre & Velasquez, 1991).
There are 2 forms of paternalism. The first is weak or soft paternalism, where the patient's wishes are ignored, but the patient has – or is suspected to have – reduced decision-making capacity, possibly due to physical limitations such as unconsciousness or extreme pain. Because of the patient's reduced ability to make decisions, it is generally accepted that doctors, in a better position to make the decisions for them, are justified in doing so. Weak paternalism is not so ethically problematic and might even be necessary. Hard or strong paternalism, however, refers to ignoring or overriding the wishes of the patient when he is fully capable of making his own decision and is the most ethically problematic form of paternalism (Culver, 1999, pp. 359-360). Since weak paternalism is generally accepted as justified, (Jackson, 2006, pp. 70) this essay will explore hard paternalism, and will argue that in reality it is not desirable to entirely eliminate strong paternalism from clinical practice.
One of the main arguments supporting paternalism is that medical practitioners are more informed and hence in a better position to make decisions. Moreover, patients may not fully understand the options available to them. The doctor might explain the medical risks involved, but it is difficult to sketch out all possible outcomes and communicate the full extent of emotional and social consequence of the options. Although the patient might be clear about his own wishes and values, the choice he makes might not bring the expected results. If he makes a decision that the doctor knows he will later regret, the doctor should step in to influence the patient's decisions.
Also, paternalism can decrease and even remove unnecessary worry and stress for patients. Paternalism often involves withholding information. For example, when a doctor observes a certain symptom in a patient, he comes up with a range of hypotheses, then runs certain tests on the patient, even though chances of the patient testing positive for most diseases is low. Choosing not to tell the patient what the test is for, in order not to cause them worry, is a form of paternalism, but is considered ethically acceptable by a large majority of people (Goldman, 1999, pp. 60). Another example of paternalism that has long been socially justified and even stereotyped occurs with terminal illnesses. The doctor at the bedside assures the patient that all is well, but comes out of the room shaking his head sadly at the family. In such cases, it might not be in the best interests of the patient and family to reveal full details of the problem.
In other cases, patients themselves are not ready for full autonomy. They might not want the responsibility of making decisions, for fear of regret later. Psychologically, it is often a defence mechanism that pushes the responsibility onto the doctor and the authority that the position brings. This subconscious safety net allows them to push the blame onto the doctor and his profession if the decision turns out to be the wrong one. This absolves the patients from blame, and the decision becomes an external factor that was beyond their control. It also has much to do with respect for the doctor’s authority and vantage point that is recognised as being better-informed, as explained previously. Often, even after patients are explained the available options, they end up relying completely on the doctors opinion.
However, paternalism has its flaws, the most obvious being that it removes the rights of patients in making decisions regarding themselves. Closely related to this is the argument that patients understand their own wishes best, and hence are best equipped to make decisions regarding their healthcare (Kleinig, 1985, pp. 115-19). The word “best”, however, is problematic because it is impossible to clearly and explicitly define what is "best" for a patient. For example, would a faster or more painless recovery be better? The debate surrounding voluntary euthanasia encapsulates this tension. Based on the patient’s “values, beliefs, and wishes”, death is preferred over prolonged suffering, but from a medical and indeed biological viewpoint, being a vegetable in pain is better than being dead. Therein lies the conflict, and where paternalism comes in is in the doctor’s decision – whether to administer voluntary euthanasia or to override the patient’s wishes based on what is deemed “best”.
In models developed by certain Americans in 1992, medical relationships can take 4 paths: the informative, interpretive, deliberative or paternalistic models. The main factor that differentiates paternalism from the other three is that the others, as their main objective, cater to the patients’ wishes (Hope, Hope, Savulescu & Hendrick 2003). The doctor might provide information, decipher the patient’s wishes, or challenge those wishes through persuasion, but ultimately it is the patient’s choice. The driving force behind paternalism, however, is to have the patient’s best interests at heart, independent of their wishes.
Historically, beneficence took precedence over autonomy. However, since the 1970’s, medicine has been confronted with the need for autonomy (Beauchamp & Childress, 1989, pp. 209-222). Thus, in the present-day society, a purely paternalistic model is not practical. This is especially so as patients value their autonomy more, feeling that they are more knowledgeable due to information regarding healthcare being more widely available. As such, the interpretive and deliberative models seem more practical to today's society as both patients and doctors take part in the decision-making process.
In conclusion, the added responsibility on the doctor in paternalism is a double-edged sword. It puts stress on the doctor to make "right decision", but the greater authority also forces doctors to consider the options more seriously instead of being merely a source of information or “consultant”. With great power comes great responsibility, and paternalism forces the doctor to become more involved, to engage, and to take greater interest in the overall well-being of the patient. This factor carries much weight, and might indeed be worth the trade-off with patient rights in some cases. As such, paternalism, although ethically problematic, does have a role in clinical practice. The question though, is how much of a role it has. It is important to find the right balance between autonomy and beneficence, and this might differ between societies with different cultural values.
Word Count: 1097
Reference List
Beauchamp, T.L. & Childress, J.F. (1989) Principles of Biomedical Ethics, (pp. 209-222), New York and Oxford, Oxford University Press
Goldman, A. (1999) The refutation of Medical Paternalism. In J.D. Arras and B. Steinbock (Eds) Ethical Issues in Modern Medicine (5th Ed), (pp. 59-67) Mountain View., Mayfield Publishing Co
Emmanuel, E.J. and Emmanuel, L.L. (1999). Four Models of the doctor-patient relationship. In John D. Arras and Bonnie Steinbock (eds) Ethical issues in Modern Medicine, (5th Ed) pp. 67-76, Mountain View CA: Mayfield Publ. Co.
Feinberg, J. (1998) The Routledge Encyclopedia of Philosophy: ‘Freedom and Liberty’ In Edward Craig, (ed.)
Healthcare ethics: Paternalism (2007), Retrieved April 10, 2008, from Ascension Health website:http://www.ascensionhealth.org/ethics/public/issues/paternalism.asp
Andre, C. & Velasquez, M. (1991) Issue in Ethics: For Your Own Good (Vol. 4 No.2), Retrieved April 5 2008, from Santa Clara University Markkula Centre for Applied Ethics website: http://www.scu.edu/ethics/publications/iie/v4n2/owngood.html
Culver, K. (1999) Readings in the Philosophy of Law (pp.359-360) Broadview Press
Jackson, J. (2006) Medical Ethics (pp. 70) Polity
Kleinig, J. ( 1985) Law and Philosophy:Paternalism (ed. 1) (vol. 4)(pp. 115-119)
Hope, R.A., Hope, T., Savulescu, J. & Hendrick, J. (2003). Medical Ethics and Law: The Core Curriculum. Elsevier Health Sciences. Retrieved April 18, 2008, from Google Books: http://books.google.com.sg/books |
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