Medical Paternalism or Patient Autonomy
At issue in the controversy over medical paternalism is the problem of patient autonomy. Medical paternalism can be defined as interfering with a patient’s freedom for his or her own well-being; patient autonomy means being able to act and make a decision intentionally, with understanding, and without controlling influences (Munson, 38 & 39). The principle of informed consent has come to be essential to any philosophical analysis of the tension between medical paternalism and patient autonomy in healthcare decision-making.
However, despite the obligatory duties physicians have to their patients, patient involvement and informed consent should be valued in certain medical cases. Consider, for example, the case of Monica, a 49-year-old woman who was admitted to the hospital for acute respiratory insufficiency. As a heavy smoker, she had been experiencing dyspnea. Upon examination it appeared she had several abnormalities in the chest. Following this she became cyanotic and nearly lost all consciousness.
Furthermore, a bronchoscopy revealed a large, tumor-like mass in her trachea. Upon further examination it was determined by a multidisciplinary treatment team that Monica was so advanced in the tumor, removing it would not be possible, either by surgery or laser. In addition, chemotherapy and radiation therapy would not have helped and implanting a stent would have been difficult. Monica had at most three more months to live.
With such factors taken into consideration, the team devised four possible alternatives: remove life-sustaining measures, continue mechanical ventilation and heavy sedation without treating any complications, implant a stent without Monica’s consent, or wake Monica and inform her on the diagnosis and possible alternatives while giving her the final choice. However, the team does not believe that Monica will have the full autonomy to make a rational decision on her own.
Furthermore, the team worry that reducing sedation while Monica is being intubated will induce tremendous physical pain. The question therefore remains whether they should wake her and inform her diagnosis and prognosis and allow her to make the decision or make a medical paternalistic decision on her behalf. Because each possible alternative presented in this case have a similar unfortunate end result, it appears that the medical ethics issue at most concern is the failure to respect the patient’s autonomy.
The principle of autonomy clearly dictates that Monica should have the opportunity to decide about her future. There are limits to imposing suffering on patients in order to grant them autonomy in decision-making, but only patients themselves can know exactly what those limits are. Therefore the caregivers must ask if Monica would prefer to be awakened from sedation at all. If so they must then consider whether she would want to participate in the difficult decision about her treatment options.
But despite these considerations, Monica has a right to be informed to a degree that she herself decides her medical fate. Therefore, the team should wake her. The harm done to her by waking her, however, should be kept to a minimum. She should know her diagnosis and prognosis, and that she can at any time delegate the decision-making power to another person and receive sedating medication. The question for Monica’s caregivers, then, is whether autonomy becomes overvalued when it conflicts with other values.
When the possibility was discussed of waking Monica so that she could decide what to do next, the multidisciplinary treatment team worried that she would not be in any position to make an autonomous decision on any possible issue when faced with physical suffering and a horrible prognosis, Consider, however, Kant’s Metaphysical Principles of Virtue. In this article Kant states that everyone is worthy in making his or her own decisions as human beings (Korsgaard). Therefore, Kant would argue that Monica’s physicians are obligated to let her make her own treatment decision.
He would even go far enough to say that the caregivers are in no position to judge her level of competence. Accordingly, Monica’s willingness to make a decision will depend on her individual level of pain and ability to learn that she is near death; it will not depend on the physicians’ judgments. Of course, not respecting Monica’s autonomy would represent a decision that could be characterized as paternalism. Oftentimes, the word paternalism is associated with physicians telling patients what is good for them, without regard to the patient’s own needs and interests.
In the larger sense, however, the relationship between physicians and patients is a paternalistic, beneficent relationship: the physicians are expected to do what is medically best for the patient, according to Dworkin (Munson, 60). According to the principle of beneficence, physicians have a responsibility to act in ways that promote the well-being of their patients (Munson, 892). Monica faces so short a life expectancy, and the quality of that life can be presumed to be so miserable, that the caregivers may ask whether waking her just for the purpose of letting her choose among her horrible options will in fact cause more harm than good.
So when deciding about Monica’s participation in the treatment decision, the caregivers are right to be concerned about whether she will truly be competent when woken up. But if the underlying concern is competency, we can make the case that she is more than capable of making a treatment decision: since there is no “best” alternative among the treatment possibilities, Monica will not be in a position of asking the caregivers to do something that will inflict harm upon herself, and thus will not have to “prove” her competency on the highest standards.
Therefore, paternalism and beneficence from this perspective is essentially irrelevant overall. The caregivers are not at a position to provide what is medically best for Monica because all options lead to about the same unfortunate outcome. In such case there is ultimately no reason why the caregivers cannot respect Monica’s autonomy at the very least. One valid argument against the respect for Monica’s autonomy is that reducing sedation in an intubated patient like Monica in order to allow her to be informed about her situation and to communicate her preferences will induce significant physical pain.
And learning in such a difficult moment that she is going to die soon of lung cancer is likely to be very painful psychologically. However, as stated previously, Monica’s willingness to accept this suffering will depend on her individual level of pain and her ability to cope with both pain and learning that she is near death. Perhaps even more importantly, it will depend on whether there are important things in her life that she would like to accomplish before she dies.
Many patients would like at least to say goodbye to their loved ones or clarify a relationship after a recent dispute. Monica might want to make a will or indicate how and by whom her affairs should be handled after her death. Such factors are extremely important to consider upon the last few months of a patient’s life.
- Korsgaard, C. M. , Autonomy in Kant’s Moral Philosophy. 1990
- Munson, R. Intervention and Relfection. Boston: Clark Baxter, 2012. Wadsworth Cengage Learning.