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.