Goldman’s Refutation of Paternalism and its Exceptions

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.

1 thought on “Goldman’s Refutation of Paternalism and its Exceptions

  1. Iris Wickham

    Leah is very thoughtful in her descriptions and refutations of multiple significant points discussed by Goldman. She demonstrates his defense of the prioritization of subjective harm over objective harm. This likely relates to Goldman’s focus on the theory of “value orderings,” which is a personal list of hierarchical preferences that ring true to someone’s intrinsic beliefs and principles. The key to this theory is the idea that it is subjective, and the precedence of quality of life vs. quantity of life will differ among patients, and therefore subjective harm cannot be infringed upon by a doctor or they will be at risk of stripping them of their fundamental value ordering. However, a possible critique of value orderings and Goldman’s beliefs within medical practice is his lack of acknowledgement of those with mental illness. In cases where the patient physically cannot make decisions in their best interest, paternalism is likely necessary in some capacity. I agree with Leah’s challenge of Goldman’s argument that paternalism is justified when withholding information from patients about their condition. It seems that he undermines his own central thesis by concluding this, and as Leah describes, it directly contradicts his beliefs on subjective and objective harm. And while Goldman acknowledges that paternalism may be necessary in some cases, this doesn’t nuance his larger argument and he seems to look them over. Does Goldman really give these few cases enough attention? And is the theory of “value orderings” really sustainable for all of the population?


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