Question

Is Dworkin right that certain kinds of strong paternalism are justified? Why? Under what conditions?

Is Goldman right that we cannot assume that prolonged life is a patient's top priority? Which of his arguments made the most sense?

Is Ackerman right that we need to go beyond the non-interference model if we are to show true concern for autonomy? What level of paternalism would be justified?

Answer 1

#. Paternalism," Gerald Dworkin

Dworkin accepts the notion (famously articulated by John Stuart Mill) that society may sometimes justifiably restrict a person's liberty for purposes of self-protection or the prevention of harm to others. But he takes issue with Mill's related anti-paternalistic idea that a person "cannot rightfully be compelled to do or forbear because it will be better for him to do so." He argues that some limited forms of state paternalism can be justified, for "[u]nder certain conditions it is rational for an individual to agree that others should force him to act in ways which, at the time of action, the individual may not see as desirable." In a representative government, rational people could agree to restrict their liberty even when the interests of others are not affected. But in such cases the state bears a heavy burden of proof to show "the exact nature of the harmful effects (or beneficial consequences) to be avoided (or achieved) and the probability of their occurrence."

#. "The Refutation of Medical Paternalism," Alan Goldman

Except in a few extraordinary cases, strong paternalism in medicine is unjustified, Goldman argues. Patients have a right of self-determination, a right of freedom to make their own choices. Decisions regarding their own futures should be left up to them because persons are the best judges of their own interests and because self-determination is valuable for its own sake regardless of its generally positive effects. This right implies "the right to be told the truth about one's condition, and the right to accept or refuse or withdraw from treatment on the basis of adequate information regarding alternatives, risks and uncertainties." The faulty premise in the argument for medical paternalism, says Goldman, is that health and prolonged life can be assumed to be the top priorities for patients (and so physicians may decide for patients accordingly). But very few people always prioritize these values in this way.

#. "Why Doctors Should Intervene," Terrence F. Ackerman

Respect for patient autonomy is distorted when autonomy is understood as mere noninterference, says Ackerman. On this prevalent hands-off view, "[t]he doctor need be only an honest and good technician, providing relevant information and dispensing professionally competent care." But this approach fails to genuinely respect autonomy, he argues, for it does not recognize that many factors can compromise autonomy, including illness and a host of psychological, social, and cultural constraints. At times, true respect for autonomy may require the physician to intervene, to deviate from the patient's stated preferences. The goal of the physician-patient relationship should be "to resolve the underlying physical (or mental) defect, and to deal with cognitive, psychological, and social constraints in order to restore autonomous functioning.