Chapter 3: Paternalism and Patient Autonomy

Shades of Autonomy and Pateernalism

- Autonomy → person’s rational capacity for self-governance or self-determination. It is
an individual’s power to deliberate about available options, to choose freely among those
possibilities, and to act accordingly. We fully exercise our autonomy when our choices
and actions are truly our own, free from the overriding pressure of people and
factors that rob us of control.
- Limitations on a person’s autonomy can be physical or psychological, obvious or
subtle, justified or unjustified, and generally accepted or widely controversial.
Physically restraining a patient violates his autonomy, and so does misinforming
him about the seriousness of his illness.
- Ex: Using false information to persuade her to have the operation is a
subtler compulsion.
- Paternalism → overriding a person’s actions or decision-making for his good.
Society has placed more value on the rights of patients to know important facts about
their medical care, to make choices regarding their medical treatment, and even to refuse
treatment that physicians recommend.
- Weak Paternalism → refers to paternalism directed at persons who cannot act
autonomously or whose autonomy is greatly diminished.
- Ex. dangerously psychotic, severely retarded, extremely depressed,
or acutely addicted.
- Weak paternalism is not usually considered an objectionable violation of
autonomy because patients are already substantially nonautonomous to
some degree.
- Generally, it is thought to be morally acceptable because its purpose is to
protect people from harm while they are nonautonomous, to determine if
they are in fact nonautonomous, or to restore them to full autonomy.
- Strong Paternalism → is the overriding of a person’s actions or choices even
though he is substantially autonomous.
- Cases involving strong paternalism often provoke debate and sometimes
legal wrangling.
- Ex: A physician discovers that his patient has a malignant breast
tumor, but because he knows she is terrified of the disease, he tells
her that the tumor is benign and should be surgically removed just
in case
- Ex. A woman who needs a life-saving blood transfusion refuses it
on religious grounds, but when she lapses into a coma, surgeons
operate and give her the transfusion anyway.
 - Many people are staunchly anti-paternalistic, condoning (as most do) acts of weak
paternalism but rejecting all forms of strong paternalism. They argue that strong
paternalism is wrong because it violates the rights of persons to determine
for themselves what is good and what is right.

Refusing Treatment
- Until the late 1980s, the right of competent patients to turn down treatments ordered by
physicians was unsettled.
- In some situations, patients were thought to have no right to decline recommended
treatments.
- Parents who for religious reasons reject medical treatment for their children insist on the
right to decide what’s best for them and sincerely believe what’s best is avoiding medical
interventions.
- They demand the freedom to practice their religion as they see fit.
- But others have argued (including the courts) that though parents may decide
many matters on the well-being of their children, they do not have the right to
bring serious harm to them, especially since children cannot decide such
issues for themselves.
- Nevertheless, many argue that if adolescents are not competent to decide such things,
competent adults (including physicians and nurses) should step in to protect their
welfare, even if intervening means defying religious doctrine.
- Courts have created the rule that a competent patient has a right to reject recommended
treatments, even life-saving ones.
- The right to refuse treatment is problematic when:
- 1) The patients are “mature minors”
- 2) Parents reject medical treatment for their minor children.
- Ex: Due to religious beliefs
- Physician Autonomy → The freedom of doctors to determine the conditions they work
in and the care they give to patients.
- Pressures on physicians
- 1) Penalties for low productivity
- 2) Pharmaceutical companies that encourage use of expensive treatments of
marginal efficacy
- 3) Patterns of physician reimbursement that encourage procedure-oriented
interventions and minimize counseling

Futile treatment
- The classic pattern of paternalism involves a physician who wants to treat a patient who
prefers not to be treated.
 - But sometimes things happen the other way around—when the patient or the
patient’s family wants a treatment that the physician, typically from beneficent
motives, does not want to provide.
- The main moral conflict is between patient autonomy and the physician’s view of
what constitutes morally acceptable care.
- Medical Futility → the alleged pointlessness or ineffectiveness of administering
particular treatments.
- Ex: providing a ventilair treatments to patients even when you know they
are going to die in a few days
- Physicians are not obligated to provide treatments that are inconsistent with
reasonable standards of medical practice.
- They are not morally bound to comply
- Ex. when a patient requests that his legs be amputated for no reason or demands
injections of a worthless and dangerous cancer remedy.
- Futility is a question of values–what should be done in the circumstances
- The sharpest clash in such a situation is between physicians and those who argue for the
sanctity of human life because in that case the moral imperative is to keep the body alive
at all costs and the physicians claim is insignificant.

Refusing treatment for children on religious ground

- Several children have died after their parents refused medical treatment because of
religious beliefs.

CPR and DNR

- The medical procedure used to restart a person’s heart and breathing is known as
cardiopulmonary resuscitation, or CPR, consists of mouth-to-mouth resuscitation and
external chest compression
- do-not-resuscitate order, or DNR → is a directive telling the medical staff to forgo CPR
on a patient if his heart or breathing stops.
- DNR orders are generally thought to be medically appropriate and morally
permissible when the performing of CPR on seriously or terminally ill patients
would be ineffective or futile and would only prolong dying or intensify the
patient’s pain and suffering.

Moral conflicts in nursing

- They must come to terms with many of the same moral questions and principles that
weigh so heavily on physicians:
- Beneficence versus Patient Autonomy,
- Patient-Provider Confidentiality,
 - Truth-telling,
- Refusal of Treatment,
- Informed Consent
- Futile Treatment.
- The traditional notion of a nurse is that of a caregiver subordinate to physicians and
duty bound to carry out their directives for patient care and treatment.
- But for many nurses this model seems fraught with conflicts between the nurse’s
obligation to follow the doctor’s orders and the nurse’s duty of beneficence
toward patients.
- Nurses may wonder whether they have this sort of duty to physicians even when doctors’
orders seem clearly to be in error, or likely to harm patients, or obviously in violation of
patients’ autonomy, or evidently contrary to well-established standards of care.
- Some writers have defended the traditional model of nursing, arguing that (at least in
hospitals) physicians must always be the ultimate authority on treatment in urgent
or serious cases.
- After all, only doctors have the requisite training and experience to deal with such
situations, and for the sake of efficiency, their decisions should not be questioned.
- The nurse’s proper role is therefore subservient.
- But others reject the traditional model, arguing instead that the nurse’s ultimate
responsibility is to be an advocate for patients, that adopting a subservient role
would likely harm patients, and that blindly following physicians’ orders does not
serve the patient well.

The 4 Models of Physician-Patient Relationship

- 1) The Paternalistic model
- The aim of the physician-patient interaction ensures that patients receive the
interventions that best promote their health and well-being.
- 2) The Informative model
- The aim of this interaction is for the physician to provide the patient with all
relevant information, for the patient to select the medical interventions he or she
wants, and for the physician to execute the selected interventions
- 3) The Interpretive model
- The aim of the physician-patient interaction is to elucidate the patient’s values and
what he or she actually wants, and to help the patient select the available medical
interventions that realize these values.
- 4) The Deliberative model
- The aim of the physician-patient interaction is to help the patient determine and
choose the best health-related values that can be realized in the clinical situation.
- Patient Values
- Informative → Defined, fixed and known to patient
 - Interperative → Inchoate and conflicting, requiring elucidation
- Deliberative → Open to development and revision through moral
discussion
- Paternalistic → Objective and shared by physician and patient
- Physician’s Obligation
- Informative → Providing relevant factual information and implementing
patient’s selected intervention
- Interperative → Elucidating and interpreting relevant patient values as
well as informing the patient and implementing the patient’s selected
intervention
- Deliberative → Articulating and persuading the patient of the most
admirable values as well as informing the patient and implementing the
patient’s selected intervention
- Paternalistic → Promoting the patient’s wellbeing independent of the
patients current preferences
- Conception of Patient’s Autonomy
- Informative → Choice of, and control over, medical care
- Interpretive → Self-understanding relevant to medical care
- Deliberative → Moral self-development relevant to medical care
- Paternalistic → Assenting to objective values
- Conception of Physician's Role
- Informative → Competent technical expert
- Interpretive → Counsler or adviser
- Deliberative → Friend or teacher
- Paternalistic → Guardian

Applying Major Theories

- Utilitarianism → can justify paternalistic actions in the case they promote the greatest
good for patients and minimize suffering and maximize well-being.
- Act Utilitarianism → justifies paternalism in the case where a physician may judge that
it is morally permissible to lie to a patient about a beneficial treatment to overcome
patients refusal to be treated.
- Rule Utilitarianism → however would suggest that lying will produce more harm in the
long term because it would create distrust in the medical profession.
- Kantian Ethics → also rejects paternalism because the means-ends form of categorical
imperative insists on respect for the rights and autonomy of persons–respect that must not
be weakened by calculations of utility/paternalistic urges to act for a patient's own good.
- Informed consent is also viewed as mandatory and misleading patients about
treatment is not permissible. These rules are necessary to avoid treating the
patient simply as a means and not an end.
 - In cases of medical futility Kantian ethics argues that if a physician believes a
treatment is pointless, then giving it would be unethical and their withholding of
the treatment is permissible and forcing the physician to do what they think is
wrong would violate their autonomy.
- Natural law theory → is more paternalistic than Kantian ethics espcially in cases of
euthanasia.
- The Doctrine of Double Effect → would deny a terminally ill patient's request to have
medically assisted death.
- The Roman Catholic corollary to this is that a hopelessly ill patient has the right
to refuse extraordinary life sustaining treatments–measures that cause
suffering/hardship but no medical benefit.