Paternalism and Patient Autonomy

1
Paternalism and Patient Autonomy

• Vaughn, Chapter 3
• Pp 51-62

2
Autonomy

• What Autonomy is
• Autonomy is a persons 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 059. I
wont let you! lol!
4
Paternalism, Weak and Strong

• What paternalism is not
• Stopping someone from harming others (sometimes
  called delegated police authority)
• Overriding a patients wishes in order to benefit
  the hospital, doctor, nurse, etc.
• Overriding the patients wishes when they
  conflict with the health care providers values

5
Paternalism, Weak and Strong

• Strong Paternalism (sometimes called extended
  paternalism) overriding of a competent
  patients wishes
• Weak Paternalism (sometimes called cooperative
  paternalism) overriding of an incompetent or
  doubtfully competent patients wishes (Vaughn
  differs a bit, p.52, paragraph 2 prefer ppt
  definition)

6
Paternalism, Weak and Strong

• Strong Paternalism overriding of a competent
  patients 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 anothers 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 patients wishes
• Courts have accepted weak paternalist excuses
  when overriding the patients wishes is required
  to relieve the patients 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 patients 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 its 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? Isnt suicide always wrong?

16
Applying Major Theories

• On page 57, the book says Natural Law theory is
  more paternalistic than Kantian ethics, but
  doesnt say why.
• Why should it be?
• What is the doctrine of double effect?
• Read the six examples under Applications here
  http//plato.stanford.edu/entries/double-effect/
• How does the doctrine apply in the context of
  Paternalism vs. Autonomy?

Consider trolley car scenario using notion of
double-effect, ending at 936. (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 Childs Death
• Do you agree with the courts 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 Courts 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 hospitals decision to
  withdraw care?
• Do you agree with the childs 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?