Detailed Study Notes on Paternalism and Autonomy

Paternalism and Autonomy

Definition of Paternalism

• Interfering with a person's liberty of action.
• Reasons for interference:
  • To benefit them.
  • To make them better off in the long run.

Examples of Paternalism

• Parent to child control: Parents make decisions for their children, believing it's in the child's best interest.
• Medical scenarios: Stepping in for someone with conditions like dementia who can't make informed decisions.
• Legal and Governmental examples:
  • Taking kids out of a neglectful home.
  • Seat belt laws: Mandating seat belt usage despite some people's objections.
  • Cell phone usage laws: While partly about preventing harm to others, they also protect the user.
  • Taxes on smoking: Discouraging smoking for the benefit of individuals, despite objections from smokers.

Libertarianism vs. Paternalism

• Libertarianism: Holds that paternalism in any form is wrong.
• Dominant View: Seeks a balance between individual control over one's destiny and allowing outside intervention in certain cases.
• Middle-of-the-road View: Most people lean towards a middle ground, but the exact point on the spectrum is debatable.

Onora O'Neill's Approach

• Paternalism is sometimes justified when individuals have diminished capacity to reason.
• The default position is that adults have the right to make their own decisions.
• Considerations about paternalism should be based on the variable and partial character of actual human autonomy.
• Human autonomy is affected by:
  • Emotions.
  • Information availability.
  • Reasoning abilities, statistically and logically.
• Autonomy exists on a sliding scale, influenced by capabilities, knowledge, and emotional state.

Fundamental Values in Medical Concern

Autonomy

• If autonomy is the fundamental value, it justifies respecting patients and their wishes.
• Problem: Some individuals lack autonomy (e.g., unconscious patients, children, dementia patients).
• If autonomy is missing, it doesn't justify treating the person with any respect, which leads to issues such as doing medical experiments on comatose patients.

Beneficence

• Definition: Doing good for someone, taking care of their interests.
• Problem: If beneficence is the fundamental value, it disregards the importance of autonomy.
• Autonomy and degrees of autonomy should influence how patients are treated.

Result-Oriented Ethics (Consequentialism, Utilitarianism)

• Synonyms: Result oriented ethics, consequentialism.
• Utilitarianism: Autonomy matters only if it affects the outcome.
• Beneficence outweighs autonomy in result-oriented ethics. The goal is to maximize overall well-being.
• Paternalism is only misplaced when it reflects miscalculation of benefits, but if the intentions are pure the action is acceptable.
• Utilitarians value autonomy and positive character traits conditionally, as long as they contribute to good outcomes.

John Stuart Mill's Utilitarian Justification for Autonomy

• Each person is best informed about their own life, resources, capabilities, and happiness.
• Paternalism is often a miscalculation because individuals are better judges of their own happiness.

Problems with Mill's View

• Lack of evidence that individuals always make the best decisions for themselves.
• Analysis paralysis: Too many options can overwhelm individuals, leading to poor decisions.
• Even if Mill is correct, autonomy only "tends" to be better, without a rock-solid guarantee.
• Utilitarianism may still override autonomy if calculations suggest a better outcome by doing said override.

O'Neill's View on Result-Oriented Ethics

• Result-oriented ethics cannot adequately justify the importance of autonomy.

Action-Oriented Ethics (Deontological Ethics)

• Focuses on intentional action.
• Autonomy is a necessary condition for deliberation and action.
• Autonomy is crucial for having value, dignity, and being praiseworthy or blameworthy, so respect is always due.

Problem with Deontological Ethics

• Some people lack autonomy, but this shouldn't mean they lack respect or that anything is acceptable to do to them.
• Deontology can’t allow for mistreatment of people lacking autonomy.

O'Neill's Modification to Action-Oriented Ethics

• Respect the fact that some patients lack some features of autonomy while still having others.
• Allow for partial autonomy.
• Instead of an ideal model of autonomy and consent, opt for a partial and actual model.
• Account for the varying levels of rationale, reasoning ability, and awareness of consequences.

Ideal vs. Actual Consent and Autonomy

Ideal Model

• Based on what someone would agree to if they were a fully informed, rational reasoner.
• Every person has a "best self" that is fully informed and capable of optimal reasoning.

Problems with the Ideal Model

• Can justify paternalism because it disregards the actual patient's compromised reasoning.
• The ideal reasoner would agree to things that the actual patient might not, leading to overriding the patient's wishes.
• Ideal conditions need to be met in order for a person to be autonomous.

Actual Model

• Base concern for patients on their actual capabilities for consent and autonomy.
• Determine when actual consent is genuine and significant versus spurious or misleading.

O'Neill's Belief

• Make it possible for patients to consent by:
  • Bringing patients up to speed.
  • Explaining information in an understandable way.
• The messiness of this approach doesn't bother her.
• Concern for medical autonomy is centered upon the patient, not the doctor.
• Patients need to be able to accept or reject proposals.
  *Medical practice respects patient autonomy when it allows patients, as they actually are, to refuse or accept what is proposed to them.

Formalizing Consent

Impossibility of Formalization

• The ways in which human autonomy is limited are highly varied.
• Established procedures cannot absolutely guarantee genuine consent.

End User License Agreements

• Nobody reads end user license agreements, and they frequently do not hold up in court.

Consent Forms

• Consent forms might be routinized, but they cannot ensure that everyone who signs has legitimately consented.
• Verbal consent, power of attorney, can embody compromised interest which violates what the patient would want even if the legal requirements are met.

Consent and Consequences

Limiting Consent

• It is impossible to consent to all possible consequences.
• Focus on the fundamental stuff in policy.
• Patients should be in a position to agree or disagree with what is happening to them.
• Trivial and ancillary aspects of action proposals may not need formalized consent.

Coercion and Deception

General Prohibition

• Coercion and deception prevent legitimate consent, even for ideal reasoners.
• Misinformation or forcing a decision invalidates consent.

Fundamental vs. Non-Fundamental

• Coercion and deception about the fundamental stuff is off limits.
• Doctors may be allowed to coerce or deceive about non-fundamental aspects.

Examples

• Placebos: Deception about inert pills can have powerful effects.
• Restraining a patient: Coercion may be necessary but not fundamental to the procedure. It may be necessary to avoid patients flinching.

Questions and Concerns

Fundamental Definition

• The question of what constitutes "fundamental" is raised.
• It is up for debate whether fundamental is what a doctor or patient understand to be of fundamental importance.

Perspective Matters

• Blood transfusions can be standard for doctors but violate religious beliefs of patients.
• Perspective may be the defining factor in determining whether a component of a proposed medical procedure is "fundamental" or not.

Summary

• Actions of the goals of medical practice have to serve what the patient's aims are.
• Our goals have to be considered when we're talking about the difference between paternalism and non-paternalistic practice.

O'Neill's Final Proposal

Summary

• Medical practice should assess autonomy on a case-by-case basis.
• Autonomy should be made possible for patients whenever practical.

Potential Drawbacks

• This approach might be impractical due to the amount of work required.
• Standard procedures, despite their flaws, might be the best compromise.