Category Archives: Patient autonomy (week 5)

Alan Goldman: Priority of Health and Prolonged Life in Rational Thought

In “The Refutation of Medical Paternalism”, an excerpt from Alan Goldman’s The Moral Foundations of Professional Ethics, Goldman argues for faulty premises stated in medical paternalism. Specifically, he claims that it is intrinsically wrong to assume most human beings prioritize health and prolonged life in rational thought. In actuality, Goldman believes very few people classify health in this regard due to many other underlying motivations in one’s life that may be prioritized. Therefore, paternalistic interference would not be necessary and or matching the autonomy, values, and beliefs of the patient.

Goldman explains that if health and longevity are at the top of moral decisions, then social policy should follow the same. For example, our entire federal budget should be spent on health-related issues and defensive war, in which lives are risked and loss is rational, would not take precedence over biological existence and quantity of life. Furthermore, he states that personal lives often engage in “risky” activities just for pleasure and or convenience. It would not be irrational to trade quality for quantity when assessing one’s longevity. Lastly, Goldman brings up the point of people with bad states of consciousness, such as mental health detriments and depression. He argues that it may be better off to not prolong this suffering, so the instrumental worth of being alive is no longer a priority to those suffering from these mental illnesses. 

The logic behind Goldman’s thoughts and evidence for his argument is clear and concise. However, I do not agree that very few people do not prioritize health and prolonged life when it revolves around patient and physician, or nurse, relationships and moral action in our society. From an ethical standpoint, one’s autonomy can not be completely fulfilled without being fully aware of their moral view. To achieve this, they must be in good health (or consciousness) and have grown to a certain extent of moral thinking. For example, the claim that parents can make decisions regarding their child’s health due to less knowledge regarding their moral judgments. Hence, longevity is necessary to have moral growth and a “corrected” autonomy. With this longevity, quality and quantity of life both increase, countering Goldman’s claim. Autonomy is, arguably, the most important principle in bioethical reasoning with an imperative connection to health and longevity. Therefore, many people prioritize their health status and longevity in moral judgments. 

In respect of Goldman’s argument and evidence, I believe that the idea of social policy also prioritizing health and medical longevity is a strong assumption that every single person prioritizes their health. As a majority, most people prioritize their health when referring to morality. Yet, I do agree with Goldman that some people may have different priorities; but in different situations. For example, an elderly family member suffering to stay alive and preserving life may not be their choice. Combining my criticism and Goldman’s argument, most people prioritize their health and prolonged life for their moral decision-making, especially regarding a physician and a patient relationship, in most medical situations.

Goldman’s Principles of Medical Paternalism

Goldman’s principal argument against the standardised view of paternalism dictates that paternalism relies on there being an objective way to order certain values – such that the preservation of life is always the highest possible value in any medical situation. He argues that paternalists take that view that, in any context, if it is possible to preserve being, then this should be the primary goal, above all other things. This argument appears to agree, in premise, with the instinctive nature of doctors who are trained to use all possible skills to preserve the lives of their patients. Looking at this solely from the perspective of a medical physician this argument seems valid and transparent. Why would there ever come a situation in which saving the life of an individual is the wrong thing to do?

However, Goldman challenges this argument from a wider perspective, it is evident there are some arguments.  His main argument is that the ranking of these values is not objective and is in fact subjective – personal to each being. Some patients may have higher values than the simple act of preserving their own life. I have experienced this subjectivity first-hand with my 97-year-old great- grand-mother who, for many years had signed a DNR because she felt that she had lived her life and felt no need to be resuscitated. Late in her life she was diagnosed with aggressive throat cancer, given only 3 weeks to live she asked to be given no treatment. She asked to be left alone because the pain of the treatment was not worth the short lengthening of her life. Despite going against the view of preservation being the aim and the passing of my family member, personally I am more content with this outcome because as a viewer seeing someone close to you suffer for a long period is almost as bad as their passing.

While Goldman’s argument about the importance of subjective value ordering seems reasonable (and accords with my own personal experiences), there are a number of situations where it becomes harder to sustain.  In short, it relies upon the ability of the patient to make an informed decision about their relative value ordering.   There are a number of circumstances where this might be brought into question.  First,  an individual who is diagnosed with depression or is considered psychologically unstable may have a tainted view on their own ranking of values. Further, patients may be suffering emotional coercion (from family members for example).  In such circumstances, paternalistic values may be seen as having an appropriate role in protecting the individual from his/her self.  The position is further complicated in individuals who are unable (physically or legally) to give an informed view on their hierarchy of values (minors, for example, as they do not have the ability to decide for themselves). In these circumstances it is difficult to draw the distinction as to who should make the decisions; the parents; the medical professional; the state. In these specific scenarios some may consider it easier to move back to the paternalistic view that life should always be preserved at the main priority.

Goldman does present a well-argued attack on paternalism by focussing on the issue of objective value ordering.  However, the societal pressure to preserve life (ingrained in the medical professional’s training) and the numerous circumstances where real objectivity cannot be assured, means that relying solely on a doctrine of objective value ordering to supplant paternalism is likely to be dangerous.  By focussing solely on the rights of ‘an’ individual, rather than considering the wider good (the impact on family, the medical profession, healthcare costs etc.) objective value ordering perhaps represents an overly narrow avenue of attack on medical paternalism.