MEDRADSC 3Y03 - Paternalism

Paternalism

Acting in a way that is believed to protect or advance the interest of a person, even if this goes against the person’s own immediate desires

Can paternalism still occur when patients are cooperating?

Yes

What does paternalism limit?

Limits someone’s choices or freedom whether it conflicts with their desires or autonomy

2 types of paternalism

Weak and strong paternalism

2 extremes in medicine

Doctor has total control or pt has total control

Principle of bioethics that dominates the other 3

Autonomy

“Since illness often damages autonomy, concern to respect it does not seem a promising fundament principle for medical ethics”

O’Neill

O’Neill’s proposal

Paternalism is justified to the degree that the pt’s decision making power is diminished

When is paternalism justified?

• Temporary or permanent loss of autonomy

• Long term or permanent impairment of autonomy

When is paternalism not justified?

When the pt has some degree of decision-making powers

What r/s does paternalism in medicine mimic?

Parent-child

When does a 3rd party typically make decisions on pt’s behalf?

When pt cannot make their own decisions

Historical trend regarding paternalism in medicine over the last 50 years

Moving away from it, towards empowering pt choice or autonomy

What 2 core principles of bioethics must be balanced when considering paternalism?

Beneficence and autonomy

O’Neill’s primary criticism of using autonomy as the fundamental principle

Since illness often damages autonomy, concern to respect it is not a promising fundamental principle

According to O’Neill, who is responsible for determining a pt’s decision-making capacity?

Physician

A sole focus on the principle of beneficence alone would leads to what degree of paternalism?

Total or maximum paternalism

Why can’t autonomy be the sole consideration in medical ethics?

Autonomy is undermined by illness or injury

Why can’t a doctor obey both autonomy and non-maleficence in all cases?

A pt’s autonomous choice may lead to harm

Weak paternalism

You know what’s best for you and we’ll help you do it

Strong paternalism

We know what’s best for you and we’ll help you do it

According to Stirrat and Gill, the dominant paradigm in bioethics until recently has been the autonomy of the _____.

patient

Stirrat and Gill argue that the individualistic paradigm of autonomy is a(n) _____ application in medical ethics.

aberrant

What revision do Stirrat and Gill recommend for the twenty-first century regarding patient autonomy?

A revision of its operational definition towards a principled version.

How do Stirrat and Gill define their proposed 'principled version' of patient autonomy?

Providing sufficient information and space for capable patients to make a settled, responsible choice that is considerate to others.

Stirrat and Gill suggest that the dominance of the individual autonomy paradigm has tended to replace medical paternalism with what other form of paternalism?

Bioethical paternalism.

What is a potential negative consequence of doctors unthinkingly acquiescing to a patient's requested intervention against their clinical judgment?

It is an abrogation of their duty as doctors, not an honoring of patient autonomy.

According to Onora O'Neill, Kantian autonomy is not a form of self-expression but rather a matter of acting on principles of _____.

obligation

Onora O'Neill contrasts 'individualistic autonomy' with what she calls '_____ autonomy'.

principled

In Kant's account of moral autonomy, there can be no freedom for an individual if that person acts without reference to all other _____ _____.

moral agents

Stirrat and Gill argue that if patient individualistic autonomy is the sole criterion for decision-making, the patient-doctor relationship is reduced to that of _____ and _____.

client and technician

What are the two models of autonomy suggested by Schneider?

Optional and mandatory.

Which model of autonomy, according to Schneider, entitles but does not require a patient to take an active role in decision-making?

The optional model.

Which model of autonomy, according to Schneider, considers it morally objectionable for a patient to forswear making medical decisions personally?

The mandatory model.

According to Confucius, as cited by O'Neill, what is the last thing a ruler should give up, which is essential for a moral community?

Trust.

O'Neill states that trust is needed precisely when and because we lack _____ about others' future actions.

certainty

The patient-doctor relationship has traditionally been seen as _____ rather than contractual.

covenantal

In a covenantal relationship, what is at the heart of the mutual, unspoken agreement between doctor and patient?

Mutual trust.

What are the central obligations of the doctor in the traditional covenant relationship?

Competence, compassion, caring, and good communication.

Draper and Sorell argue that medical ethics is 'one-sided' because it dwells on the ethical obligations of doctors to the exclusion of those of _____.

patients

In the context of public health versus individual benefit, Brock and Wartman suggest that patients do not have an unqualified right to make rational choices that risk serious _____ to others.

harm

The term '_____' is often preferred over 'informed consent' because it implies offering options from which patients can indicate their preference.

informed choice

In shared decision-making, what two key things do patients bring to the dialogue with doctors?

Their narrative and knowledge of their own subjective aims and values.

A competent patient has the legal right to _____ medical treatment or intervention, even if that refusal is medically irrational.

refuse

A doctor may be ethically justified in refusing a patient's request for treatment if, in their informed opinion, the risk of the procedure _____ the potential benefits.

outweighs

According to the student presentation, paternalism in medicine mimics a _____ relationship.

parent-child

What is the general definition of paternalism provided in the presentation slides?

Acting in a way believed to protect or advance a person's interest, even against their immediate desires.

The presentation slides state that medicine has historically been paternalistic but has been moving towards empowering _____ in the last 50 years.

patient choice or autonomy

In bioethics, which principle is often thought of as the 'first among equals,' dominating the others?

Autonomy.

Why does O'Neill argue that concern for patient autonomy is not a promising fundamental principle for medical ethics?

Because illness often damages autonomy.

According to O'Neill's proposal in the presentation, paternalism is justified to the degree that the patient's _____ power is diminished.

decision-making

The presentation states that considering beneficence alone leads to total or maximum _____.

paternalism

When is paternalism justified, according to the summary in the presentation slides?

When there is a temporary, long-term, permanent impairment, or permanent loss of autonomy.

In O'Neill's article, she states that since illness often damages autonomy, concern for _____ is generally thought to be a more plausible fundamental principle for medical ethics.

patients' well-being (beneficence)

In utilitarian ethical thinking, when is respecting a patient's autonomy morally required?

Only when doing so fortuitously maximises welfare or well-being.

Why are John Stuart Mill's claims about autonomy maximizing happiness considered empirically dubious by O'Neill?

Because many patients want relief from hard decisions and the burden of autonomy.

In an action-oriented ethic, why must the autonomy of agents be of basic, rather than derivative, moral concern?

Because autonomy is a presupposition of agency, which is central to this ethical framework.

What is the parallel in medical ethics to the political debate over express vs. tacit consent?

The debate over whether explicit consent (forms) is required versus implicit consent (placing oneself in a doctor's care).

O'Neill argues that the notion of an 'ideal rational patient' cannot stand up to scrutiny, suggesting that the _____ model of human relations is questionable in medicine.

contractual

What does O'Neill mean by the 'opacity of consent'?

That consent is always to an action under certain descriptions, and we don't necessarily consent to all its logical implications or likely results.

What is the danger of shifting focus from what a patient has *actually* consented to, to what an *ideally* autonomous patient would consent to?

It replaces concern for the actual patient's autonomy with a hypothetical one, potentially justifying paternalism.

According to O'Neill, to respect others' autonomy requires that we make _____ possible for them, taking into account whatever partial autonomy they may have.

consent

O'Neill argues that medical practice relying on routine signing of 'consent forms' may avoid litigation but does not necessarily show concern for ____.

human autonomy as it actually exists

What is the key difference between coercion and deception in how they preclude consent?

Deception means cognitive conditions for consent are not met; coercion means volitional conditions for consent are not met.

How does O'Neill distinguish manipulators from paternalists?

Manipulators use knowledge of others' weaknesses to impose their own goals; paternalists may not even recognize that the goals they impose are not the patient's.

In an action-oriented framework, a patient's own goals and plans act as _____ on any medical practice that respects their autonomy.

constraints

According to O'Neill's contextual view, what determines the boundaries between permissible and impermissible paternalism?

The determinate cognitive and volitional capacities of particular patients at particular times.

In the case of temporarily impaired autonomy, O'Neill suggests this offers grounds for paternalistic intervention specifically to _____ autonomy.

restore

For patients with permanent loss of autonomy, what question might staff ask to maintain elements of respect for the patient as they were?

'What would this patient have chosen in this situation?'

In what situation, according to O'Neill, is the notion of respect for autonomy considered vacuous, leading to unavoidable and indefinite paternalism?

In cases of lifelong incapacity for autonomy.

Stirrat and Gill believe that medical ethics should always be set in the context of _____ and community.

relationships

The conceptual framework of bioethics has traditionally accorded paramount status to the value-complex of _____.

individualism

O'Neill claims that John Stuart Mill hardly ever uses the word 'autonomy', and when he does, it refers to _____ rather than individuals.

states

According to O'Neill's interpretation of Mill, his version of autonomy sees individuals reflecting on and _____ among their desires, not just implementing them.

selecting

The dominant view of individualistic autonomy in recent liberal bioethics is that it confers a 'right to act on one's own judgment... without _____ by others'.

interference

What is the scarcest of medical resources, according to Illingworth?

Trust

Schneider found that the principle of autonomy is strikingly absent in the concerns of people who are actually ____.

sick

What is the primary focus of 'managerial ethics' in healthcare, as contrasted with patient-centered 'physician ethics'?

Setting the stage for formations of collective action by a large number of individuals (systems-focused).

At what level is trust ultimately gained and bestowed in healthcare delivery?

At the level of the individual healthcare professional.

What concept, according to Atkins, goes beyond empathy by trying to understand what it is like for that person to be himself or herself?

Consideration of the subjective character of experience.

What is one way a patient can manifest taking responsibility for an autonomous decision, according to Draper and Sorell?

Accepting a known risk of an adverse outcome if the procedure is performed competently.

In O'Neill's article, she states that a central tradition in agent-centred ethics has been unhelpful because it has taken an abstract and _____ view of human autonomy.

inaccurate

Medical cases where autonomy is reduced are not anomalies for consent theory but rather _____ cases that highlight the typical limits of human autonomy and consent.

revealing

Serious respect for autonomy demands that a patient's refusal or consent is based on their understanding of the _____ of their diagnosis and proposed treatment.

basics

According to O'Neill, using patients as unwitting experimental subjects or concealing fundamental aspects of their illness constitutes _____.

using them as tools or instruments

When a patient has some capacity for autonomy, imposing others' goals on them is considered unacceptably _____, even if not deceptive or coercive.

paternalistic

O'Neill's action-oriented framework insists that judgements of human autonomy must be _____, varying with the situation.

contextual

The attack on medical paternalism was a key reason for the rise of the _____ paradigm in bioethics.

patient autonomy

The student presentation poses a key question in medical ethics: 'How do we balance _____ and autonomy?'

beneficence

According to the student presentation, a doctor cannot obey both autonomy and _____ in all cases.

non-maleficence

What is the term for when a doctor's exercise of their own autonomy and clinical judgment is mistakenly attacked as paternalism?

Fulfilling their duty to the patient.

In a result-oriented ethical framework, paternalism is only considered morally wrong if it reflects a _____ of benefits.

miscalculation

The 'informed consent' model is most appropriate for a _____ model of human relations, which O'Neill argues is a poor fit for medicine.

contractual

O'Neill asserts that if a medical proposal hinges fundamentally on coercion or deception, not even the most _____ and independent person can truly consent or dissent.

rational

Respecting partial autonomy requires avoiding treatment which, though refusable by an ideally autonomous person, would not be refusable by a particular patient in their _____ condition.

present