The conflict between patient autonomy and physician paternalism is the basis of countless bioethical issues. In Alan Goldman’s Refutation of Medical Paternalism, he argues that there are few justifications for abandoning patient autonomy.
Goldman begins by explaining two types of harm. The first is objective harm, which includes events that are viewed universally as undesirable, such as physical injury, hastened death, or depression. No rational being would wish any of these situations upon themself. Subjective harm, on the other hand, is when someone’s autonomy or ability to freely and creatively make decisions regarding their own life is blocked in some way. While any person can experience subjective harm at some point, it can look different for everyone and can be avoided if physicians respect patients’ wishes.
Goldman argues that subjective harm is, in the long run, more damaging than objective harm. He makes it clear that quantity of life is not as important as quality of life, and that it is not worth trying to prolong someone’s life if it goes against their wishes and beliefs for how they should live their life.
One area where I disagree with Goldman is his argument that paternalism is justified when withholding information from patients about their condition. Although telling patients about an upsetting diagnosis may increase the likelihood of depression and physical deterioration, not every patient’s priority is prolonging their life. If someone is terminally ill, they deserve to know and use this information to prepare for the end of their life. Goldman argues that we can assume someone prioritizes a prolonged life if they place themselves under a physician’s care, but this isn’t a fair assumption to be made. In the case of a terminally ill patient, they may prioritize their comfort over a prolonged life, so knowing about a poor prognosis for their illness may lead them to request an assisted suicide. Even when someone is terminally ill and it’s too late to preserve their life, they should at least be given the dignity of keeping their autonomy intact. Choosing not to tell a patient about their prognosis goes against Goldman’s argument that subjective harm is more damaging than objective harm.
Overall, Goldman’s argument is full of valid points, but I believe his support of paternalism when not informing a patient of their condition goes against his own argument of valuing autonomy over the length of someone’s life.