In “Refutation of Medical Paternalism,” an excerpt from his larger work The Moral Foundations of Professional Ethics, Alan Goldman enumerates a plethora of cogent critiques against strong medical paternalism, but perhaps the most salient aspect of his argument is in articulating that the paternalistic notion that patients always prioritize health and prolonged life when seeking medical care is vastly unfounded. In order to do this, he begins by examining the definition of harm. While admitting that prioritizing the autonomy and self-determination of the patient may bring about some physiological and medical disadvantages, he believes that the subjugation and suppression of the patient’s free thinking and moral autonomy poses a broader and more significant threat to his identity. In order to substantiate this train of thought, Goldman particularly examines what he believes to be the core of an individual’s identity: value orderings. By altering the state of affairs through interference without consent, medical practitioners risk bringing about a state of affairs that are lower on the patient’s scale of value orderings, since values are intrinsically subjective and operate on a deeply personal basis.
In order to truly understand this strain of Goldman’s argument, we must analyze its central component of value orderings. He poses a number of scenarios in which rational persons would not solely prioritize the minimization of the loss of life, such as choosing not to devote the entire federal budget towards healthcare or opting to engage in defensive war. He expects this same level of moral and ethical nuance to be applied to the practice of medicine as well. Indeed, these positions are not without merit. Rational thinkers with strong religious convictions, for example, prioritize their values vastly differently from members of the scientific community. There are people who may choose a medical treatment plan that, while being less effective in curing a particular ailment or prolonging life, may provide more comfort and better quality of life to the individual. An autonomous, self-determining individual has every right—nay, obligation—to allow his convictions to dictate which course of treatment he chooses. In further critiquing Goldman’s ideas, I analyzed them through the lens of larger ethical theories, and I began to see his argument as, essentially, a critique of utilitarianism. He understands that the weakness of the formula of utility is that it only focuses on the consequences of the actions, and not the moral intent or inherent character of the actions themselves. I found this to be an extremely compelling understanding of how strong paternalism prioritizes only the mere biological existence of patients, even at the cost of their subjective values.
However, there are some practical issues with Goldman’s arguments. He assumes that every patient is a rationally thinking individual who may only refuse certain treatments due to his personal convictions, but he fails to consider the actions of mentally disabled patients. These patients do not have the cognitive capacity to develop this “value-ordering” he prioritizes, and hence, are not able to distinguish between various medical states of affairs and the harm those scenarios may cause to their subjective values.
Kris Chari analyzes and evaluates the claim of “Refutation of Medical Paternalism” by Goldman. According to Chari, Goldman argues that the assumption of people prioritizing in health and a prolonged life is not always true. Goldman also argues that harm done by depriving of the patient’s autonomy and hence personal identity is greater than the possible harm done by disclosure of the patient’s true medical status. He also explains that people do not always prioritize in saving the most amount of people, and that people may have different preference in values.
Then, he evaluates Goldman’s arguments by saying that his arguments are a critique of utilitarianism as it only focuses on the consequences of the actions, and not the moral intent or inherent character of the actions themselves.
He also brings up the problem of mentally disabled patients, and states that they may have problems with deciding their own “value orderings” due to their diminished mental capabilities.
However, one potential criticism of Chari’s analysis is that it ignores people’s tendency to be influenced by other’s actions when making value judgments. The lack of paternalism in society will allow people to participate in self-destructive behavior, which will inevitably influence the value judgments of other people including children.
Also, I do not agree with Chari’s view that Goldman opposes utilitarianism, as Goldman is essentially comparing the difference in utility generated when people autonomously decide to refuse medical treatment by abiding to their values in contrast to when they are lied about their condition.
In regards to his argument about mentally disabled people, the philosophical question of “personhood” comes into mind. As Chis states, autonomy is not always present within all ‘persons’ such as in mentally disabled, people in permanent coma and infants. If autonomy is a privilege that only certain groups of person’s can have, we need to question whether in a state without paternalism, it is just to allow only those with autonomy to choose what they wish to do in regards to medical practices, while abandoning others without autonomy to suffer due to a lack of agent that could decide what is best for them.