Transcript Health Care Ethics Ch. 2

Vaughn, Chapter 3
What Autonomy is:
Autonomy is a person’s rational capacity for selfgovernance
Its value is expressed in the Autonomy Principle:
Autonomous persons should be allowed to
exercise their capacity for self-governance
–Vaughn, p.51
2
Paternalism = benevolent action
irrespective of or even
contrary to the wishes of the
beneficiary.
The term paternalism comes
from Latin, pater, meaning
father … fatherly.
As such, Paternalism is always a
violation of patient
autonomy, though perhaps
justified, depending on
circumstances.
3
Click the image above (when
in Slide Show mode) for a
youTube video …. see short
scene of Paternalism in
action beginning at 0:59.
“I won’t let you!” lol!
What paternalism is not:

Stopping someone from harming others
(sometimes called “delegated police
authority”)

Overriding a patient’s wishes in order to
benefit the hospital, doctor, nurse, etc.

Overriding the patient’s wishes when they
conflict with the health care provider’s values
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Strong Paternalism (sometimes called extended
paternalism) = overriding of a competent
patient’s wishes
Weak Paternalism (sometimes called
cooperative paternalism) = overriding of an
incompetent or doubtfully competent
patient’s wishes (Vaughn differs a bit, p.52,
paragraph 2; prefer ppt definition)
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Strong Paternalism = overriding of a competent
patient’s wishes
Is Strong Paternalism ever justified?
For government:

To protect the rights of others

To protect an overriding state interest (is this
the basis for prohibiting suicide?)
Are these technically ‘paternalistic’?
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The government, however, has not authorized
health care providers to use strong paternalism
…
-Garrett et al., p 41, paragraph 2 (Book is cited on slide 17;
you do not need to retrieve this book)
Garrett provides …

inability to know another’s values and

the possibility of multiple acceptable choices
as reasons to reject strong paternalism.
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Weak Paternalism = overriding an incompetent or
doubtfully competent patient’s wishes:
Courts have accepted weak paternalist excuses
when overriding the patient’s wishes is required
to relieve the patient’s serious pain or suffering
Weak paternalism is also mitigated if exercised to
gain informed consent. Garrett calls such “in the
service of autonomy.” Vaughn says as much p.52
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Restraints: restraints are justified on weak
paternalistic grounds when patients are
confused or disoriented, posing a danger to
themselves. Their use should include
safeguards:

Periodic patient visits

Approval of supervisors and or physicians

“Written justification”
9
Garrett notes trepidation regarding paternalism
on p 42:
“we insist that there is no general authorization
for even weak paternalism. Each case needs
to be studied, and exceptions should be
made carefully.”
10
The law has recognized paternalism under the
name Therapeutic Privilege.
Therapeutic Privilege = the privilege of
withholding information from the patient
when the physician believes that the
disclosure will have an adverse effect on the
patient’s condition or health.
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3 conditions guide the use of therapeutic privilege:
1.
Its use must not be based on generalities, but on
the actual circumstances of the particular
patient
2.
The physician must have a founded belief, based
on intimate knowledge of the patient, that full
disclosure will have a significant adverse effect
on the patient
3.
Reasonable discretion must be used in the
manner and extent of the disclosure
12
Garrett dislikes this legal device; notes 2
problems with it:

Research fails to confirm full disclosure
adversely effects patient condition or health

It is a denial of patient autonomy
13
Vaughn notes that sometimes physicians and
patients disagree in reverse … the patient
wants treatment and the physician refuses.
Can happen over …
 amputation fetish
 worthless or unproven drugs, but more often,
 Sanctity of life v. Futility
14
Look at pp 56, 57.
 Utilitarians will be tempted to use Paternalism.
Why?
 How can J.S. Mill think it’s okay to let someone
ruin their life (supposing they choose to die or
shorten their life by refusing treatment)?
 How can Kantian physicians allow someone under
their care to commit suicide by refusing
treatment? Isn’t suicide always wrong?
15
On page 57, the book says Natural Law
theory is more paternalistic than
Kantian ethics, but doesn’t say why.
Why should it be?
What is the doctrine of double effect?
Read the six examples under
“Applications” here:
http://plato.stanford.edu/entries/double-effect/
How does the doctrine apply in the
context of Paternalism vs. Autonomy?
16
Consider trolley car
scenario using notion
of double-effect, ending
at 9:36.
(Click image in Slide
Show mode for
youTube video)
What would a Virtue Theorist think … or, how
would Aristotle go about deciding whether
Paternalism is always, sometimes, or never
justified?
17
Vaughn, L. (2010). Bioethics
Garrett, T. M., Baillie, H. W., Garrett, R. M.
(2001). Health Care Ethics (4th Edition)
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Case 1 – Prayer, Medicine, and a Child’s Death
Do you agree with the court’s decision to
reverse the manslaughter conviction?
Should parents have the right to refuse medical
treatment for their children on religious
grounds?
What moral principle would support your
judgment?
See the rest on page 60, Vaughn.
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Case 2 – State Paternalism and a Pregnant Woman
 Do you agree with the Supreme Court’s decision?
Why or why not?
 Should the state force pregnant women to
behave in certain ways while carrying a fetus?
 Is a pregnant woman guilty of “fetal abuse” if she
refuses to eat properly?
 Drinks any amount of alcohol?
 Forgoes prenatal care?
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Case 3 – Medical Futility
Do you agree with the hospital’s decision to
withdraw care?
Do you agree with the child’s parents?
Do you accept the sanctity of life view, or think
quality of life should determine what to do in
cases like this?
How do you justify your view?
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