In refuting the practice of Medical Paternalism, Alan Goldman focuses mainly on the ideological theory of “value orderings”; defined as the order of one’s life priorities, and how medical paternalism fundamentally violates this doctrine. Goldman argues that medical practitioners cannot accurately assume that a patient’s top value is prolonging their life, because intrinsic moral values are completely subjective on a personal basis. Goldman continues his confutation by discussing the relationship between subjective and objective harm, and concludes with a rebuttal of paternalistic assumption of moral authority. Therefore, according to Goldman’s argument, Medical Paternalism is almost never justified because doctors cannot accurately assume one’s value orders, and thus should not act paternally because of the subjectivity of individual moral codes.
To conduct an informed analysis of this argument, we must first understand the main anatomical piece- Goldman’s idea of value orderings. This can be understood as the order in which an individual “ranks” his life priorities. The reason Goldman takes issue with Paternalism is because it assumes that the prolonging of life is at the top of everybody’s value orders. Goldman disputes this assumption, as everybody’s value orders are completely subjective- a doctor cannot accurately estimate a patient’s priorities without deep interpersonal knowledge of every patient- a task that would be virtually impossible. Goldman argues that the autonomy to decide and uphold one’s values takes precedence over “mere biological existence” (124). I read this to mean that the nature of one’s life may be more important than its’ length- such as a terminally ill patient opting for assisted suicide.
The other important aspect of Goldman’s argument is his idea of subjective vs objective harm, and how they stack up against each other. For him, objective harm is as such: physical injury, death, depression- something no rational person would wish on themselves. Subjective harm is when someone’s autonomous development (aka their life projects/value orderings) are blocked and externally interfered with. His argument claims that subjective harm is likely to cause more hurt than objective in the long run, as it fundamentally invalidates one’s “integrity as an individual” (121), since something other than his ideal state of affairs will be actualized. Respecting the autonomy of the person may cause objective harm, but that harm cannot be used as an excuse to disrespect one’s free will.
I agree with Goldman in almost every sense of this argument. However, when evaluating his argument, some issues arise. When Goldman identifies the concept of the value order, he does not analyze the case of psychologically impaired patients. For example, a clinically depressed person may make life choices that do not align with his usual life priorities. Secondly, Goldman defends his value order theory by using the example of people putting quality over quantity in relation to their lives, such as people taking risks to enrich their lives. I have to wonder if this is truly representative of the population, and if it is, if this concept of a pleasure-oriented life can be used in a medical sphere, where doctors are bound by the Hippocratic Oath. One must consider if there is a clash between the overarching medical goal to prolong life and the enrichment-oriented life goals argued by Goldman.
In Jake’s comment, he mentions the absence in Goldman’s argument of any prolonged discussion of mental illness or states of mental incapacity. It would be very difficult to identify an individual’s true “value ordering” without some certainty that she is expressing her real preferences and not simply acting or communicating randomly as the result of an impaired state. The absence of impairment would seem to be a prerequisite for effectively applying Goldman’s theory. I think this is a really important caveat and would leave open the possibility for justifiable paternalism in cases of mental impairment, even if one accepted the rest of Goldman’s argument.
Dworkin touches on something similar when he talks about the prohibition against selling oneself into slavery. Dworking says that this prohibition should be justifiable to anti-paternalists because it protects the very thing anti-paternalists pursue when they oppose paternalism: individual autonomy. If we allowed people to sell themselves into salvery, we would allow them — through the use of his free decision making — to entirely abdicate free decision making going forward. This seems like a contradiction that would completely undermine the main idea of the anti-paternalistic theory. Similarly, if we give overriding weight to preferences conveyed during states of mental unfitness, especially if those preferences might put the individual’s life at risk, we could be undermining the liberty of the person rather than honoring it. The person’s capacity for decision making would be cut off without our being sure that the decision to do so accurately reflected the person’s desires. Dworkin argues that paternalism should be acceptable to all when it helps ”to preserve a wider range of freedom for the individual in question” (117). The case of a patient who’s mentally incapacitated, just like the case of a person who seeks to sell himself into slavery, would seem to accord with Dworkin’s rule about preserving a wider range of freedom. The question, obviously, is how we distinguish legitimate preferences, however bizarre, from decisions that are the result of mental unfitness. Do we have to use criteria about what a reasonable person would doin order to establish mental fitness or its absence? If that were the case, then the justification for paternalism through mental capacity would potentially be circular.