Category Archives: Patient autonomy (week 5)

Personal Reflections on Goldman’s Arguments

Whenever I ask a question, my least favorite response is always “it depends”. I am constantly searching for the correct answer to each problem, and do not enjoy being told that, in some situations, there isn’t one. In regards to the debate of paternalism versus autonomy, the answer is quite often “it depends”. It is not possible to say that every use of medical paternalism is completely unjustified, because each situation, person, age group, motivation, and medical condition is different. Alan Goldman’s work focuses on how paternalism factors into these separate situations, showing just how complex the topic is. Goldman breaks his argument against paternalism into two sections: empirical and moral. In the empirical section, he brings up the point that it is impossible for physicians to know if patients will actually be negatively affected if they are fully informed. Physicians will not always properly calculate risk-benefit, so they should not have the power to decide for the patient, thus refuting the argument for paternalism. With this argument, though, the use of paternalism depends on the physician’s ability to understand the patient and their possible reactions. If there is a physician that is able to perfectly calculate the risk-benefit, and knows that the patient will be happier if they are kept in the dark, then paternalism would be justified. 

When focusing on the moral argument, Goldman stresses the important role that personal values play in paternalism. The fundamental outline of paternalism is based on the idea that health and prolonged life take full priority over patients’ personal preferences. Many would argue that modern medicine’s goal is to prolong life, so physicians are simply doing their jobs by doing everything to keep their patients alive. Some patients value making their own decisions more than the length of their life, though. If a physician decides to withhold medical information or move forward with treatment, the patients that value self-determination will not have an improved quality of life. Goldman concludes his moral argument by saying that these values are present because they are upheld by rational beings that deserve to make personal decisions. Taking away a person’s ability to choose can threaten their individuality. In these specific instances, paternalism does seem to be morally wrong. In individuals that do value health and long life over decision making, a physician interfering with the patients’ liberty would be valid. Paternalism is therefore an issue that depends on individual values and situations. 

Though Goldman primarily argues against it, he does acknowledge that paternalism can sometimes lead to good. There is no perfect example of an instance where paternalism should overrule autonomy, so the answer must be: “it depends”.

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.

A commentary on Dworkin’s Paternalism

Gerald Dworkin, a philosophical pioneer of the idea of paternalism, argues that there may exist parameters where a person, in present time, may not want to partake in a particular action, but at another time, may understand the positives of said action and agree to others paternalistically forcing them to commit said action. This avenue of thought paves way for paternalistic legislation and governance, which pervades common contemporary society. Laws and rules are put in place for the benefit of all whom reside within the law’s jurisdiction. Seeking out every citizen’s approval before instating society-wide limitations or practices, like taxes or drug illicitation, is near impossible in growing societies, which begins a path of instability for Dworkin’s framework of paternalistic governing. This framework proves potentially unethical to assuage a platform of limitation to the masses without formally taking into account the value prioritization of those who are being affected on a constant and rolling basis. Paternalism would then only be validated in scenarios which there is no class or hierarchy system associated with the beneficiaries of any said law or restriction. Dworkin defines this subsidiary of paternalism as Pure paternalism. In the same vein of thought, Dworkin would argue that patients who provide consent to treatment in the beginning stages of treatment, are powerless to refuse or halt care if the practicing physician deems the patient to have lost rationality in the process. There is no certainty within that assumption, which provides more room for grey area in the conversation of the morality of medical paternalism. How can one be certain that a doctor, who is getting paid for performing any said procedure or treatment, has no implicit or explicit biases that influence their decision of continuing on with a patient’s care. An alternative process that should be considered for evaluative and medical ethicality is one where the patient is provided with many opportunities to express their distaste in continuing treatment, upon which ethical conclusions may be drawn as to what next steps to take, as opposed to forcing the patient to assimilate with whatever the physician decides as best. 

Goldman’s Argument to Reduce the Presence of Paternalism

In “The Refutation of Medical Paternalism”, Goldman makes his case for why paternalism is often incorrect in the medical field, when dealing with patients. In addition, Goldman dives into the various arguments promoting Paternalism, their fundamental roots of understanding, and uses that to extract various counterarguments that disprove said advocations for paternalism in the medical field.

Goldman’s argument against paternalsim starts with the understanding that every individual has their own set of values that are often ranked differently compared to the next person. Not every person will value health over all other “priorities”. Many, as seen in case studies, will value their religious practices over their health, if the two contradict. That said, giving a physician, nurse, or any healthcare delivery professional the right to override their (aware/functioning) patient’s desires-whether disclosed by the patient or not-would be a complete violation of thier autonomy. This leans on the principle explained by Goldman, that in order for a medical professional to make such a decision, they would have to have a full psychological analysis of the patient, and a deep understanding of the patient’s values, which is nowhere near possible to do consistently and efficiently.

That said, Goldman’s passion is expressing the seriousness of not assuming what is best for the patient is a critical part of his argument against paternalism. Goldman suggests that although a medical professional may know what is medically best for a patient, opposing the patient’s wishes would be even more harmful to the patient because, in that moment, the patient knows what’s best for them. However, when patients are suffering and struggling with their illness, Goldman explains that if lying to the patient would help ease some of the patient’s mental suffering, it can be done, but cautiously and when with a thorough psychological evaluation of the patient, while being able to maintain the lie. This could be another method of protecting the interest of the patient since Goldman’s objective is essentially to do that.

Dworkin’s justification for Paternalistic measures

In “Paternalism”, Gerald Dworkin brings to light inconsistencies found within Mill’s “one very simple principle” against the application of paternalism. He uses logical blind spots found within Mill’s argument to support his notion that there are such occasions in which interfering with a person’s liberty for the sake of his own good can be justified. He structures his argument around the two largest fallacies he sees in Mill’s work. The first being Mill’s assumption around impeccable adult psychology and thus unchallenged self-interest, an assumption Dworkin deems as “fairly weak” when taking into account the short-comings of ignorance, irrationality, and stupidity found within even the most reasonable adult. The second being Mill’s exception to intervene in the case that an individual makes a decision that will ultimately restrict his future freedoms.

Dworkin presents his argument with real-life scenarios in which people are understood to act in non-rational fashions using himself as an example when he reflects on failing to put on a seatbelt. His lack of emotional awareness for the potential consequences, one of those being actual death, is commonplace since few of us persistently act in our best interest all the time. In this non-rational framework, he includes decisions that are made under extreme psychological and sociological pressures as well as decisions that are made with incorrect proportions of considerations/values. As most adults would agree, these self-destructive manners are not irregularities but instead quite normal within our daily behaviour, thus Dworkin suggest paternalistic measures have the potential to serve as “social insurance policies” in which a fully rational individual is protected against his/her/their own deficiencies.

He expands this concept of insurance policy towards Mill’s second exception in which case the current decision of the individual inhibits their future autonomy and freedom. Both Mill and Dworkin agree that the objective of paternalism in such a case is to ensure the absolute value of choice itself and thus is justified.  Overall, Dworkin ends his argument with what I would consider two reasonable principles in justification of some extent of paternalism: that there must be a seriously clear burden of proof on the authorities to demonstrate the nature of the harmful effects to the individual and the principle of the least restrictive alternative that prioritizes a path that does not restrict liberty and achieves the desired end. There is a trade-off but Dworkin’s argument does hold validity.

What about Doctor’s Autonomy–an opinion on “The Refutation of Medical Paternalism”

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.

A Broader Critique of Alan Goldman’s Value Orderings

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. 

Gerald Dworkin and Consent to Paternalism

In the text “Paternalism,” Gerald Dworkin argues that there are conditions where a person may not wish to take an action at the time of that act, but at another time, when they are thinking rationally and are able to recognize the benefits of the action, they would agree to let others force them into the same act. Under such circumstances, Dworkin would consider paternalism to be valid.  Dworkin applies this argument to the larger context of government and the creation of paternalistic legislation. He argues that certain laws are put in place for what is recognized overall by the people in a community to be in their best interests, even if  those people may not wish to obey that law after it is enacted. Dworkin offers the example of taxes. When the time comes for citizens to pay taxes, they might wish not to do so. However, it is in the community’s best interest that they do so in order for the government to provide public goods. Hence, it is the government’s responsibility to continue to enforce tax laws even if citizens may not wish to pay them. Dworkin argues that paternalism in these laws and others are justified because citizens may give their consent to a system of government to limit their autonomy in order to “safeguard” their interests. 

Dworkin’s argument does have merit. Paternalistic laws and legislation may be needed in order for a society to function, and realistically, not every citizen can be asked to give direct consent to a law before it is put in place. However, I do take some issue with the lack of clarity on what it means to give consent to a system of governance. For example, are you consenting to be governed paternalistically by simply being a citizen of a country? Furthermore, the argument relies on the assumption that a citizen’s initial consent is valid. A person may give their consent to paternalistic governance due to their inability to join another state or because of pressure to assimilate into a country’s culture. This consent would not be coming from the person’s genuine trust in a government body to act rationally in their best interests when they themself are unwilling to do so. 

Further issues can be found with Dworkin’s argument when it is placed in the context of medical care. Based on Dworkin’s argument it could be proposed that if a patient gives consent to a treatment plan early on, their physician is free to continue treatment if they believe the patient to be irrational when they later object to treatment whether the patient is truly irrational or not. Additionally, the problem once again arises of what it means to give valid consent. How can we be certain a patient is not being coerced into receiving treatment by others in their life? The best way to be certain of a patient’s consent is to provide them with multiple opportunities to withdraw it, something Dworkin’s argument does not take into account.

Goldman’s Refutation of Medical Paternalism- An Analysis

In refuting the practice of Medical Paternalism, Alan Goldman focuses mainly on the ideological theory of “value orderings”; defined as the order of one’s life priorities, and how medical paternalism fundamentally violates this doctrine. Goldman argues that medical practitioners cannot accurately assume that a patient’s top value is prolonging their life, because intrinsic moral values are completely subjective on a personal basis. Goldman continues his confutation by discussing the relationship between subjective and objective harm, and concludes with a rebuttal of paternalistic assumption of moral authority. Therefore, according to Goldman’s argument, Medical Paternalism is almost never justified because doctors cannot accurately assume one’s value orders, and thus should not act paternally because of the subjectivity of individual moral codes. 

To conduct an informed analysis of this argument, we must first understand the main anatomical  piece- Goldman’s idea of value orderings. This can be understood as the order in which an individual “ranks” his life priorities. The reason Goldman takes issue with Paternalism is because it assumes that the prolonging of life is at the top of everybody’s value orders. Goldman disputes this assumption, as everybody’s value orders are completely subjective- a doctor cannot accurately estimate a patient’s priorities without deep interpersonal knowledge of every patient- a task that would be virtually impossible. Goldman argues that the autonomy to decide and uphold one’s values takes precedence over “mere biological existence” (124). I read this to mean that the nature of one’s life may be more important than its’ length- such as a terminally ill patient opting for assisted suicide. 

The other important aspect of Goldman’s argument is his idea of subjective vs objective harm, and how they stack up against each other. For him, objective harm is as such: physical injury, death, depression- something no rational person would wish on themselves. Subjective harm is when someone’s autonomous development (aka their life projects/value orderings) are blocked and externally interfered with. His argument claims that subjective harm is likely to cause more hurt than objective in the long run, as it fundamentally invalidates one’s “integrity as an individual” (121), since something other than his ideal state of affairs will be actualized. Respecting the autonomy of the person may cause objective harm, but that harm cannot be used as an excuse to disrespect one’s free will.
I agree with Goldman in almost every sense of this argument. However, when evaluating his argument, some issues arise. When Goldman identifies the concept of the value order, he does not analyze the case of psychologically impaired patients. For example, a clinically depressed person may make life choices that do not align with his usual life priorities. Secondly, Goldman defends his value order theory by using the example of people putting quality over quantity in relation to their lives, such as people taking risks to enrich their lives. I have to wonder if this is truly representative of the population, and if it is, if this concept of a pleasure-oriented life can be used in a medical sphere, where doctors are bound by the Hippocratic Oath. One must consider if there is a clash between the overarching medical goal to prolong life and the enrichment-oriented life goals argued by Goldman.

Dworkin on Paternalism and Patient Autonomy

In “Paternalism”, Gerald Dworkin negates John Stuart Mill’s position on paternalism by asserting that individuals are not always rational and paternalism does not actually conflict with patient autonomy. Mill supposes that individuals are the most interested persons in themselves, and therefore, will make the most rational decisions regarding what is best for them. However, when discussing intervention in the governmental sphere, Mill makes a few exceptions that seem hypocritical to his stance on paternalism: 1) individuals may lack exactly what it is they need, making them unqualified to make judgements alone and 2) individuals may make irreversible decisions that affect their future, therefore, stripping them of self-determination at that future moment. 

Dworkin suggests that such exceptions are equally as valid for paternalism. In Mill’s first exception, intervention is simply a means to help one achieve a need of which they are incapable of obtaining without guidance. In a medical context, maintaining one’s own health is generally viewed as a priority, and nurses and physicians are generally the most knowledgeable about how to promote good health for a patient who currently lacks such health, so paternalism is justified. With Mill’s second exception, Dworkin essentially argues that in certain situations, supporting paternalism actually gives the patient more autonomy than the alternative. He disagrees with Mill’s assumption that people always act rationally, and in such instances when people have lapses in judgement, paternalism is justified to make decisions that that person would have made in a more rational state of mind, to honor one’s previous requests (e.g. Dworkin’s Odyssey example, DNR), or to protect their future autonomy (e.g. Dworkin’s slavery example).

Ultimately, Dworkin builds a strong affirmative case for paternalism by pursuing a largely consequentialist, or more specifically, utilitarian framework. By contending that, in certain cases, paternalism provides the most autonomy as a whole despite the deprivation of autonomy in the present moment, Dworkin proves that the general positive utility of paternalism outweighs the brief negative utility. Now, Dworkin never disregards opposing arguments; he recognizes that one of the main difficulties in drawing a line for cases in which paternalism is ethical is that people may prioritize different values. In order to address this, he largely adopts a case by case mindset, only really arguing that paternalism should be implemented when the restriction is trivial in nature and does not overwhelmingly interfere with the conception of one’s own life. To strengthen his case, he proposes that to maximize total utility, authorities should always bear a heavy burden of proof and follow the least restrictive alternative. He presents numerous hypothetical situations to exemplify viable cases for paternalism, and being that even just one of these hypothetical situations stands true, Dworkin successfully upholds his argument.