Reading Guide:

The Hippocratic Oath

Here’s what you need to know:
Doctors have a reputation for paternalistic conduct towards their patients as your reading makes clear.
So, two questions: [1] What conduct earns this label? And [2] How would doctors justify such an
approach?

Review: What is paternalism?

Remember from our reading covering the principle of autonomy, paternalism is that conduct that is
both coercive and aimed at promoting the best interests of the coerced individual. To coerce someone
is to force or manipulate them into acting in a way that contradicts their wishes or intentions.

Your book distinguishes two types: weak and strong. Strong paternalism involves coercing a fully
autonomous and therefore rational individual. Weak paternalism involves coercing a less than fully
autonomous and rational individual. Parental paternalism, at least for the very young, is a weakly
paternalistic. Lying to someone to keep them from doing something dangerous would be an example
of strong paternalism.

Professional Paternalism in Medicine

This sort of paternalism involves a professional acting against the patient’s wishes in order to protect
the patient from harm. What sort of examples are typical?

[1] Failure to honor treatment refusals: When a doctor or nurse treats a patient over the patient’s
stated objections. Does this happen? Look at the Elizabeth Bouvia case in your book. Not complying
with DNR instructions, as commonly happens, is another example. [DNR=Do Not Resuscitate]

[2] Withholding information from a patient in such a way as to influence the patient’s treatment
decisions.

[3] Directly lying to the patient in order to influence a medical decision: remember the dying patient’s
question regarding the fate of his family in our previous discussion?

[4] Failing to carry out medical instructions on the part of the patient. This can involve not providing
requested treatment. It can also involve withdrawing treatment the patient requests. Look at the
description of the Wanglie case in your reading.

How to Justify Paternalism in medicine

As we’ve noted, sometimes it appears that paternalism is merited. Especially when the patient, or
anyone for that matter, lacks the decision making powers necessary to make a choice, paternalistic
intervention seems appropriate, in other words, in cases of weak paternalism.
So, one way to justify the above examples is to determine when instances of paternalism are justified
in medical practice. The second way to justify examples of paternalism in medicine is simply to claim
that medical professionals in general are entitled to act paternalistically. This latter view is known as
medical paternalism.

Medical professionals will often cite the Hippocratic Oath (in your reading) in justifying such conduct:
“I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will
keep them from harm and injustice.”

Which part of this strikes you as paternalistic? Whose “ability and judgment” counts in deciding what
is beneficial?

Of course, the Oath is just a statement of policy and values; it is not a justification—that is a reason or
set of reasons that make a particular course of action right, or at least not wrong. What kinds of
reasons might support giving medical professionals total and universal authority in dealing with
patients?

Well, consider a comparable case where we give one group of people paternalistic authority over
another group and in regard to almost all decisions: parents in regard to their children. What justifies
that? What do you think would be a good answer to this question? Do you think the situation
between doctors and patients is appropriately similar.

Of course, medical professionals know more than the patient about the medical aspects of the
patient’s situation, in most cases. Would that make a difference? Is medical information the only
information that matters? Is medical information necessarily beyond the patient’s grasp?

If the answer to either of these questions is ‘no’, then justifying medical paternalism is difficult. That
does not mean that paternalism cannot be justified in specific situations involving patients. But then
we need to look at when paternalism is justified. This is the substance of the article by Gerald
Dworkin in your reading, “Paternalism.” Look at Dworkin’s examples of justified paternalism and ask
yourself is the medical situation generally like these cases? I will discuss these cases in my next reading
guide.

Alan Goldman, in “The Refutation of Medical Paternalism,” gives a negative answer to the question:
Do the ways we justify paternalism actually justify medical paternalism? We will review his reasons in
a future reading guide.