Dworkin on Paternalism and Patient Autonomy

In “Paternalism”, Gerald Dworkin negates John Stuart Mill’s position on paternalism by asserting that individuals are not always rational and paternalism does not actually conflict with patient autonomy. Mill supposes that individuals are the most interested persons in themselves, and therefore, will make the most rational decisions regarding what is best for them. However, when discussing intervention in the governmental sphere, Mill makes a few exceptions that seem hypocritical to his stance on paternalism: 1) individuals may lack exactly what it is they need, making them unqualified to make judgements alone and 2) individuals may make irreversible decisions that affect their future, therefore, stripping them of self-determination at that future moment. 

Dworkin suggests that such exceptions are equally as valid for paternalism. In Mill’s first exception, intervention is simply a means to help one achieve a need of which they are incapable of obtaining without guidance. In a medical context, maintaining one’s own health is generally viewed as a priority, and nurses and physicians are generally the most knowledgeable about how to promote good health for a patient who currently lacks such health, so paternalism is justified. With Mill’s second exception, Dworkin essentially argues that in certain situations, supporting paternalism actually gives the patient more autonomy than the alternative. He disagrees with Mill’s assumption that people always act rationally, and in such instances when people have lapses in judgement, paternalism is justified to make decisions that that person would have made in a more rational state of mind, to honor one’s previous requests (e.g. Dworkin’s Odyssey example, DNR), or to protect their future autonomy (e.g. Dworkin’s slavery example).

Ultimately, Dworkin builds a strong affirmative case for paternalism by pursuing a largely consequentialist, or more specifically, utilitarian framework. By contending that, in certain cases, paternalism provides the most autonomy as a whole despite the deprivation of autonomy in the present moment, Dworkin proves that the general positive utility of paternalism outweighs the brief negative utility. Now, Dworkin never disregards opposing arguments; he recognizes that one of the main difficulties in drawing a line for cases in which paternalism is ethical is that people may prioritize different values. In order to address this, he largely adopts a case by case mindset, only really arguing that paternalism should be implemented when the restriction is trivial in nature and does not overwhelmingly interfere with the conception of one’s own life. To strengthen his case, he proposes that to maximize total utility, authorities should always bear a heavy burden of proof and follow the least restrictive alternative. He presents numerous hypothetical situations to exemplify viable cases for paternalism, and being that even just one of these hypothetical situations stands true, Dworkin successfully upholds his argument.

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