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.

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.

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 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.