Paternalistic authority

Paternalism

Paternalism is the term used for actions taken or decisions made for another person with the intention of benefiting that person. The word is derived from the Latin word for father; the idea is that a paternalist decision is like the decision a good father would make for his child.

It is important to note that an action can only count as paternalist if it is done to benefit the other person. Actions chosen and performed to benefit the physician or health care system, or with mixed intentions, are not paternalistic but simply coercive.

Paternalistic decision making is not problematic if the person in question is incompetent [see later]. This situation is sometimes referred to as genuine paternalism. However, paternalistic decision making is problematic if the person is competent and wants to make her or his own decisions. In that case, the paternalistic action overrides the autonomy of the person. Paternalistic decision making can be justified in emergency situations, in which there is no time to consult the patient and it can sometimes be justified in a public health context, but it is rarely, if ever, justified in non-emergency interactions with individual patients. Patients may be frail and vulnerable, but as long as they want to make their own decisions, they are their decisions to make.

An increasingly common form of paternalism is what can be called informational paternalism. Informational paternalism occurs when a patient has clearly signaled that he or she does not want some piece of information about the condition [e.g., does not want to know the precise prognosis] but is sometimes given this information because the health care team thinks that it is best for him [or her] to know. This is sometimes supported by the claim that health care professionals have a duty to tell the truth to their patients. However, it does not follow that there is a duty to impress the truth on people who do not want to hear it. This is easily seen if we consider a parallel example. All of us have a duty to tell the truth to our friends, but this does not generate an obligation to provide unsolicited evaluations of their dress sense or latest haircut, even if those evaluations are true.

Virtue Ethics, Utilitarianism, and Duty-Driven Ethics

The classic paternalism of medical practice was derived fromvirtue-based ethics. In this view, the physician is a genuinely virtuous person with inherent qualities of competence, sincerity, confidentiality, and altruism, who naturally knows and does what is correct for the patient. The patient, uneducated about medicine, has to trust the physician to decide what is best. Western society and legal systems have changed substantially since paternalism flourished, giving way to practices based in the four pillars of medical ethics: respect for patient autonomy, beneficence, nonmaleficence, and justice. Many different ethical frameworks are applied in modern medicine, but two of the most prominent frameworks relevant to western medicine are utilitarian ethics and deontology.2

Inutilitarian ethics, actions are judged right or wrong on the balance of their good and bad consequences. A right action produces the most good, based on a perspective that gives equal weight to the interests of all affected parties. Utilitarian theory is compelling but falls short in defining which benefits are most important. Is it the good that all reasonable people want or the good defined by the individual patient? What if the only way to maximize good is to commit an entirely immoral act? For example, what if the only way to win a war is to systematically torture children? Outcomes of actions continue to accumulate over timewhen on that continuum is it appropriate to determine that an action was right or wrong? The good act of saving an individuals life today may be viewed through a completely different lens when, 20 years from now, that same individual is revealed as a mass murderer.

Utilitarian theory may be best when applied to analyzing broad-based policies, in decisions regarding rationing of resources, and when attempting to resolve conflicting ethical obligations between several equally interested parties.

The premise of Kantian-based ethics [also called deontologicorduty-basedtheory] is that features of actions other than their consequences make them right or wrong.Intention is more important than outcome. Furthermore, no person should use another exclusively as a means to an end, because each personis the end for which we should act. No person should be used to further the purposes of another person without that other persons autonomous consent. Kantian philosophy would forbid killing one innocent person to save another innocent person, for example.

Individualism and autonomy are valued highly in Western society, and people tend to turn to Kantian philosophy when ethical questions arise that balance the authority of the physician against the goals and values of individual patients.

Some of the toughest ethical questions in medical practice occur when the rights and desires of individual patients conflict with social policies. Clashes between deontologic and utilitarian principles are common in the intensive care unit [ICU], in managed care settings, in end-of-life care, in transplant medicine, in triage during civilian mass casualty events, and in the care of poor and older patients whose medical management is funded by the government. In each of these settings, the will of the individual patient may conflict with broader principles of minimizing expense, fairly allocating scarce resources, protecting the broader interests of many patients, and determining where and how societys healthcare dollars are best spent.

Hard paternalism, soft paternalism, and paternalism by disinformation

Paternalism essentially occurs when the shareholder superimposes the shareholders value onto the stakeholder, thereby trumping the stakeholders value. Hard paternalism is when the trumping is overt. The stakeholder has expressed his or her values but is overruled by the shareholders values. Soft paternalism occurs when the stakeholder is not provided an opportunity to state his or her values in a fully informed way. Had the neurologist simply said I am not going to prescribe dopamine agonists to you it would be an example of hard paternalism. As the neurologist did not mention the possibility of dopamine agonists, the patient was unaware that this was an option and therefore had no sense of the value of dopamine agonists; hence, soft paternalism. At least with hard paternalism, the patient could have voiced his or her concern to the contrary. There was no option in response to soft paternalism.

Another form of paternalism is by disinformation. In this case, had the neurologist simply said dopamine agonists have a higher rate of side effects and therefore I will not prescribed the medications, this would be paternalism by disinformation. The statement by the neurologist is not a fair statement of the issues related to a risk of maleficence, that being adverse effects, as discussed previously.

Implicit in paternalism by disinformation is the creation of a type of straw man argument. Alternatives other than the physicians preferred position are characterized in such terms that it is highly unlikely any reasonable patient would find the alternatives, the straw man, acceptable. The patient then defaults to the physicians position. The straw man can be subtle. In the early 2000s, tissue plasminogen activator [TPA] was found to reduce the disabilities associated with stroke, provided the activator was administered within hours after the onset of the stroke. This time requirement introduced serious logistical issues and ultimately resulted in the establishment of stroke code teams on call, typically at large academic medical centers staffed with residents and fellows. The author recalls neurologists at local community hospitals stating publicly that they would not institute such a rapid response. Their rationale was not that they couldnt administer TPA, but that it was too dangerous. One wonders whether the logistical issues were the real reason. To be sure, TPA had significant risks, which, viewed in isolation, the straw man, would seem too dangerous. However, when counterbalanced by the potential benefit, TPA is considered the treatment of choice in the appropriate circumstance that can only be when there is a timely response.

Nonmaleficence and Autonomy

The basic tenet that all medical students are taught is nonmaleficence: First, do no harm. This credo, often stated in the Latin,primum non nocere, derives from the recognition that physicians can harm as well as help. With the physician's fallibility recognized, patient autonomy is and has been for several decades the overriding professional and societal bioethical value. Autonomy recognizes an adult person's right to accept or to reject recommendations for medical care, even to the extent of refusing all care, if that person has appropriate decision-making capacity. It is the counterweight to the medical profession's long-practiced paternalism [or parentalism], wherein the practitioner determines what is good for the patient, regardless of whether the patient agrees. Coupled with paternalism is coercion, the threat or use of violence to influence behavior or choice. The august figure in white combined with implied or explicit threats remains a potent force for counteracting patients' wishes. The thrust of modern bioethics is to respect patients by honoring their autonomy [Box e10.2].

Paternalism

Paternalism is the term used for actions we take or decisions we make for another person with the intention of benefiting that person. The word is derived from the Latin word for father and the idea is that a paternalist decision is like the decision a good father makes for his child. It is important to note that an action can only count as paternalist if it is done to benefit the other person. Actions chosen and performed to benefit the doctor, the health care system, or with mixed intentions are not paternalistic, but simply coercive.

Paternalistic decision making is not problematic if the person in question is incompetent [see latter discussion]. This situation is sometimes referred to as genuine paternalism.

Paternalistic decision making is, however, problematic if the person is competent and wants to make his or her own decisions. In that case the paternalistic action overrides the autonomy of the person. Paternalistic decision making can be justified in emergency situations where there is no time to consult the patient and it can sometimes be justified in a public health context, but it is rarely, if ever justified in nonemergency interactions with individual patients.

An increasingly common form of paternalism is what can be called informational paternalism. Informational paternalism occurs when patient have clearly signaled that they do not want some piece of information about their condition [e.g., do not want to know the precise prognosis] but where they are given information nevertheless because the health care team thinks that it is best for them to know This is sometimes supported by the claim that health care professionals have a duty to tell the truth to their patients. But it does not follow from that duty, which is essentially a duty not to lie or to tell the truth if asked, that there is a duty to impress the truth on people who do not want to hear it. This is easily seen if we consider a parallel example: Every one of us have a duty to tell the truth to our friends but this does not generate an obligation to provide unsolicited evaluations of their dress sense or latest hair cut, even if those evaluations are the gospel truth!

Paternalism

Paternalism is defined as a fatherlike authority that anticipates obedience and respect under the father's caring guidance. Some medical providers may approach patient encounters with this stance and convey, either intentionally or unintentionally, the expectation that the physician's perspective will be influential in the decision-making process. Throughout much of medical history, physicians' advice and direction was rarely questioned. Contemporary clinical practice, however, has been dismissive of paternalism because it seems to usurp the patient's autonomy to make informed choices based on personal values. However, there are different types of authoritative guidance and some argue that there are circumstances which warrant paternalistic interventions. Emergency care may be needed for a patient who cannot express a preference and for whom a surrogate cannot be found quickly. In these cases, physicians must make decisions for patients based on what is medically appropriate. Such actions support the principle of beneficence because the actions are initiated to help the patient.

Types of Paternalism

When a persons own good [irrespective of her wishes] is stated as the reason why she should be told about her genetic makeup, the arguments used are paternalistic. Paternalism comes in many shapes and forms, and the justifications for the different types vary. A distinction can be made between soft and hard paternalism. Soft paternalism refers to those interventions that do not interfere with a persons right to self-determination, or include unjustified intrusions of privacy, or restrictions of her liberty. This type of paternalism is usually acceptable even to the most liberal minded. In relation to genetics, soft paternalism could take the form of public awareness campaigns on the possible benefits of finding out about ones own genetic make up. However, when we argue against a persons right not to know about her own genetic makeup, we are not talking about providing general information about genetics, but rather about forcing genetic information on people who have expressed a wish not to be informed, and this is hard paternalism.

Those who argue against the right not to know on paternalistic grounds, however, do usually think that strong paternalism is also justified, so for them this would not be an issue. The justifications for strong paternalism are threefold. Knowing about ones own genetic makeup can be seen as a benefit to the person in the long run [allows her to take control of her own life], it can be seen as a moral choice to make [we need to have all the relevant information in order to be autonomous and we need to be autonomous in order to be moral], or it can be seen as the rational choice [no rational person would choose not to know about health-related information concerning herself]. All of these can be challenged both theoretically and practically.

Legal paternalism

Unlike the two preceding principles, legal paternalism does provide arguments for making prostitution illegal. These arguments point to the various hazards to which the prostitute exposes herself: the high chance of contracting venereal and other disease [including AIDS], abusive or violent behavior of clients, exploitation by pimps and owners of brothels, extremely low social status, and ostracism by most of society. However, such arguments are flawed: they assume the validity of the legal prohibition of prostitution [as well as of its conventional moral condemnation to which the law gives expression]. All these hazards are either caused or greatly enhanced by the illegality of prostitution. If prostitution were not a criminal offense and those who engage in it were not considered criminals, they could enjoy the same level of health protection as well as the same level of police protection from violence, exploitation, and fraud as everybody else; their social status would not be so low; and they would not be treated as social outcasts. To bring up the extremely adverse effects that the legal prohibition of prostitution has on those who practice it as an argument supporting the prohibition is circular, and it is tantamount to adding insult to injury.

There is, however, one paternalist argument that is not circular in this way: the argument referring to the damage that commercial sex is liable to inflict on the personal sexual and emotional lives of those who provide it. This hazard is not a repercussion of societys condemnation of prostitution and the illegality of the practice but is rather inherent to it. The prostitute normally performs her job with considerable detachment, but this detachment is liable to spill over into her personal sex life and bring about alienation from her sexuality and various emotional problems. However, there are other types of work that expose the individual to certain serious psychological and physical hazards but that have not been made illegal on account of them.

The most that any plausible version of paternalism can justify are legal provisions ensuring that minors or incompetent persons do not engage in such hazardous work, and that competent adults are not forced or manipulated into it. This is no simple task because prostitution has often involved minors, and it has often been an occupation engaged in only under extreme pressure of social and economic circumstances, without full understanding of its nature and hazards, or because of fraud or coercion. Today, the scale and global scope of the phenomenon of trafficking of women indicate just how pressing the last of these concerns is. On the other hand, if a competent and well-informed adult makes a free choice of prostitution as a line of work, and the law prohibits her from engaging in it for paternalistic reasons, that will presuppose an explicitly moralistic type of paternalism that claims to determine and impose the real or true interest or welfare of the individual against the individuals own informed and free choice. However, this type of paternalism will be unacceptable to anyone who accords great value to individual liberty.

Paternalism, Lack of Introspection, and Difficulty Dealing with Uncertainty

The practice of medicine has long been deeply entrenched in paternalism. Physicians decide what is best for patients and patients generally embrace the physicians recommendations. The goal-setting approach is not intended to diminish the value that the physicians skills and medical knowledge bring to the decision-making process, nor is it proposed to relieve health providers of the burden that complex clinical situations create. The goal-setting process starts with the recognition that in some instances the evidence supporting the benefits of treatment may be quite clear, and the clinicians recommendations are straightforward. However, it also acknowledges that in some health states, the best science available is insufficient to guide the care of the patient.

The goal-setting approach presupposes that in the presence of tradeoffs and competing outcomes, the patient is the better evaluator in determining the health outcome that he cares about most, with the health provider identifying the clinical strategy that will most likely achieve it [Reuben, 2009; Reuben & Tinetti, 2012]. A paternalistic attitude that assumes knowledge of the patients preferred outcomes can often close the door to any meaningful goal-setting discussion.

If not sufficiently mindful of their own biases, beliefs and expectations, clinicians may inadvertently undermine the patient-centered goal-setting process. Many physicians receive inadequate or no training in introspection and in developing personal awareness of how their life circumstances and core beliefs can inadvertently shift the focus of their caregiving from the patients values and priorities to their own [Novack et al., 1997]. In order to remain effective advocates for their patients, health providers must periodically perform the necessary self-reflection to maintain a clear patient focus. Consultation with clinical psychologist team members can facilitate this process.

Another difficulty clinicians may face in the goal-setting process is the patients need to understand his or her prognosis. Accurate prognostication is often an enormous, emotionally challenging task. Acknowledgment of uncertainty when predicting outcomes and prognosis, likely to be raised during the goal-setting discussion, may be psychologically uncomfortable for many physicians and patients alike. Avoidance of such discussions may seem easier, and in some instances, physician recommendations for additional testing, specialist referrals and alternative treatment strategies are inappropriately used to substitute.