When looking at the bioethical divide between paternalism and autonomy, much of the focus is placed on the position and opinion of the patients, but it is important to include the individuals tasked with the knowledge and the experience in the situation–the doctors. This post will focus on “The Refutation of Medical Paternalism” by Alan Goldman. In this article, Goldman lays out his principles for the importance of following the patient’s wishes and respecting their autonomy.
Goldman mentions the unique circumstances that doctors must operate under throughout his essay. He notes one of the major assertions of paternalism, that telling the patient the truth may lead to the detriment of the patient’s health. He argues that these distinctions should not be the responsibility of the doctor and that the doctor should not even weigh these consequences, because the rights of the patients should always take precedence over any other factors.
He goes on to discuss the conditions where paternalism is allowed but makes a clear distinction that medical doctors should not be allowed any paternalistic freedoms. He argues that while some professionals can adopt paternalism and it will not have a strong effect on one’s life, allowing doctors to determine what is best for patients will fundamentally change the way that medicine is practiced and treated in our culture. He believes that giving doctors such freedom would allow them to lean on the principles of beneficence in order to have power over others.
I agree that the clearest way to solve any uncertainty about a patient’s wishes is simply to follow the patient’s wishes and respect their rights. This principle reminds me of Kantian ethics, putting a heavy emphasis on the respect of every rational being. The clearest way for doctors to do the morally correct thing is to respect the freedoms and choices of their patients. I think it is especially important that Goldman removes the exceptions that come along with evaluating any unintended consequences. This also follows the Kantian philosophy that making a single excuse will ultimately lead to more excuses, and in the case of patient autonomy, the deterioration of any respect, as physicians make increasingly invasive decisions.
Goldman’s argument about relative levels of paternalism gives me pause, however. He is willing to give lawmakers the freedom to practice paternalism because he believes it is fundamentally part of the philosophy that lawmakers follow and that there will be minimal impact on individuals. I think that both lawmakers and doctors work with the best interest of their constituents in mind and they both carry knowledge that will make their approach different from a layperson. I do not see how there can be a distinction between lawmakers enforcing what they believe is best for people–especially when they are sworn to act for the people–with doctors carrying out their duty to help patients. Since the principles of beneficence are written explicitly in the Hippocratic Oath, doctors cannot simply neglect or place less emphasis on this principle while practicing medicine.