Paternalism and Autonomy

Paternalism and Autonomy

 Paternalism and autonomy are ethical perspectives employed in healthcare as decision making approaches to the well-being and best interest of the patients. The element of patient autonomy has evolved into a fundamental principle of biomedical ethics, yet challenge across the cultural and ideological diversity of the people. In every ethical approach, moral principles and ideologies develop as guides to decision making in an ethical dilemma situation. When it comes to medicine, however, the autonomous principle develops as critical based on the nature and weight of decisions involved. Many consequentialist moralists consider the principle to create a limit of a patient’s decision whose consequences may affect other people. Similarly, paternalism has evolved into a critical point of debate within the principle in instances where the patient has no legal consent of their autonomy either as an underage, mentally ill or unconscious (Sjostrand et al., 2013). This paper develops an analysis of the articulation of paternalism and autonomy principles in the biomedical ethical perspectives and the diversified ethical perspectives.

Paternalism, in the basic definition, refers to an act of interference to an individual’s liberty or autonomy with the intent of preventing harmful actions on them. There are many elements of paternalism principles in life, such as laws requiring individuals to put on helmets, banning of hard drugs, and economic incentives to reduce consumption of harmful goods. While such actions in practice have a diversified acceptance, the principle’s application in bioethics and medicine philosophy is highly debated. Autonomy in medical practice presents the element of humans as self-determined and rational agents who can weigh their options in a situation and make their best interests decision.

Paternalism and autonomy coexist as both equal and different concepts based on the type of principle involved in a situation. There are two significant types of paternalism: personal paternalism and state paternalism. Personal paternalism refers to a decision of best interests based on an individual’s moral values or principles that he knows what’s best for another person. State paternalism involves a decision or action by a governmental agent attributing to the best interests of its citizenry.

In medical practices, the element of paternalism has been tested on whether paternalism principles defy the concept of autonomy and its relation to the moral rules. Further, the principle has been questioned on the guiding rules in personal paternalism, the role of the state, and the physicians who have the medical knowledge. In general terms, paternalism in medical practices adopts the concept of “do no harm” whereby, modern medical approaches may provide a decision dilemma in the cost of a cure to a particular condition. Consider a scenario where a patient is suffering from a terminal illness such as a brain tumor, and surgery may affect some of the brain activities such as the ability to walk or talk. In his conscious mind, the doctor will present a consent form on whether to do the surgery or not after briefing the patient with the options, whether a short life with all the brain activity or a long life with less brain activity. There can, however, occur instances where the patient is unconscious, and the decision is imminent on whether to carry out the surgery or not hence the need for a next of kin’s consent. The decision in many perspectives can either be in the best interests of the patient or those of the next of kin, and the paternalist decision cannot adequately present the autonomous view.

The concept of paternalism as an approach to promote autonomy adopts an ideology that the person in the state of dilemma entrusts his/her decision to the medical treatment decision-maker. In many cases, this person can be a next of kin but doesn’t necessarily have to be since the term has no legal consent in medical practices. In many countries, a critical decision on the patient’s treatment option where there isn’t a legal or proxy medical decision-maker and a conflict of interests, a judge may be appointed as a state paternalist to decide on who may make the decision. While many arguments may present paternalism as the most morally right decision in an ethical dilemma, paternalism cannot account for autonomy. According to O’Neill (1984), Mill’s concept of liberty as the basis of autonomy principle presents that only a person as an individual can act as the best judge of their own happiness and autonomy. In this perspective, the utilitarianism approach develops an understanding that only an individual knows what’s in their best interest. Paternalism, in itself, involves a different person or entity making a decision and based on the principle of autonomy, whatever that decision is will adopt an element of self-interest rather than those of the patient.

While many people develop an understanding of the autonomy principle from a utilitarian perspective, many scholars challenge an individual’s ability to make decisions about their best interests. According to Kristinsson (2009), autonomy in the libertarian concept considers an informed-consent policy as respect to a person’s decision to make their own decisions on their best interests in an ethical dilemma. According to the Belmont Report, “Respect for persons requires that subjects, to the degree, that they are capable, be allowed to choose what shall or shall not happen to them. This opportunity is provided when adequate standards for informed consent are satisfied (3),” (Kristinsson, 2009). In a challenging approach, respect for persons involves helping them with honest information for their own moral decision development. This, however, establishes a challenge since not every personal decision; however critical serves their best interests, and therefore, the rationality assumption develops as a “misleading conception of autonomy” (Kristinsson, 2009).

Autonomy and paternalism are two ethical approaches that develop not just in the decision making perspective but also in information sharing. In modern practice, the developments of the concepts have diversified and constitute not only as ethical guidelines in biomedical practice but also as legal frameworks. Consider a scenario where a child is terminally ill, and the state mandates the parents to decide on information and decisions. The parents may choose to withhold the information from the child as an approach to promote his/her best interests. In an empirical study of paternalism, Murgic et al. (2015) questioned how the element of lying or withholding information constitutes as ethical, particularly in the physician’s position restricted by legal frameworks.

Different approaches to this and other bioethical dilemmas present the fact that no specific ethical perspective presents a universal concept of humanity and its perception towards pain and suffering. An individual’s decision doesn’t always meet the rationality test from a psychological perspective. It is, however, crucial to identify that paternalism is usually perceived in negative light irrespective of the decision’s outcome and its developmental intention (Sayani, 2015). In my opinion, this develops from a general attempt to articulate the concept of paternalism and autonomy. With the rise of empirical psychological approaches to ethics and a shift from the generalizing normative theories of morality, there’s a need to shift perspectives of bioethics. Paternalism is widely accepted, not in the promotion of the patient’s interests, but the next best guide into decision making. Paternalism is a guide to decision-making in an ethical dilemma, but in itself develops as a moral dilemma.

References

Murgic, L., Hébert, P. C., Sovic, S., & Pavlekovic, G. (2015). Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country. BMC medical ethics, 16(1), 65.

O’Neill, O. (1984). Paternalism and partial autonomy. Journal of medical ethics, 10(4), 173.

Kristinsson, S. (2009). The Belmont Report’s misleading conception of autonomy. AMA Journal of Ethics, 611-616.

Sayani, A. H. (2015). Conflict between paternalism and autonomy. Journal of Clinical Research & Bioethics, 6(6), 1.

Sjöstrand, M., Eriksson, S., Juth, N., & Helgesson, G. (2013, December). Paternalism in the name of autonomy. In The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine (Vol. 38, No. 6, pp. 710-724). Oxford University Press.