In their essay, Mappes and Zembaty explore the complex relationship between patient autonomy and familial obligations. Essentially, they argue that the concept of autonomy must be reevaluated, as there is a profound need to clarify the influence of family interests in a patient’s decision for treatment. After resolving the definition of autonomy, it is imperative to consider the need for hard paternalism when patient decisions diverge from family interests.
Although medical treatments apply to individual patients, the patients must consider factors beyond themselves when determining the best course of action, such as external issues and individuals. A patient may consider a diverse range of issues, including financial burdens or familial stress, when choosing between various treatment options. As a result, the patient may evaluate external factors outside of the medical realm. One might argue that this particular practice threatens the conventional concept of autonomy, as family members exert undue influence and pressures on a patient to act in a certain manner (Ho). Under this particular argument, family members appear to threaten the patient’s decision-making ability. Thus, a fundamental question arises: does the consideration of family interests limit a patient’s autonomy, as the patient is not acting without controlling influences?
In this particular debate, it is imperative to consider the patient’s acknowledgement of familial interests. Generally, it is nearly impossible for a patient to make a decision without considering the impact on his or her family—patients tend to evaluate external factors that extend beyond their own health, happiness, and general being. Therefore, a patient’s interests can become easily intertwined with their family’s preferences. Despite the perhaps inevitable consideration of external familial interests, patients have the full authority to either act on or ignore the family’s preferences. Therefore, the consideration of family interests does not violate the patient’s autonomy, as the patient has the ability to weigh the potentially diverging obligations and determine the best course of action based on their personal preferences and values.
After establishing the preservation of autonomy in the presence of familial interests, it is important to clarify the role of the physician. Specifically, one must acknowledge the potential requirement of hard paternalism in cases when a patient’s decision does not align with the family’s interests. In the essay, the authors describe a case in which a competent stroke patient wants to rely on his wife as a caregiver, rather than entering into a nursing home (Mappes and Zembaty). If the physician respected the patient’s decision, then an intense burden will be placed on the frail wife. In addition, the patient does not yield a profound benefit by receiving care from his spouse, as he would receive better medical treatment in a nursing home. Therefore, the principals of nonmaleficence and beneficence outweigh the patient’s autonomy. Thus, the physician is justified in asserting hard paternalism to ensure the best outcome for the patient and his family.
References:
Hardwig, John. “What about the Family?” The Hastings Center Report 20.2 (1990): Web.
Ho, Anita. “Relational Autonomy or Undue Pressure? Family’s Role in Medical Decision-making.” JSTOR, 5 Feb. 2008. Web.
Mappes, T. A. & Zembaty, J. S. “Patient Choices, Family Interests, and Physician Obligations.” Kennedy Institute of Ethics Journal, vol. 4 no. 1, 1994, pp. 27-46. Project MUSE
Hi Marianna,
Thank you for such a thorough discussion of patient choices, family interests, and physician obligations. I agree that the principles of nonmaleficence and beneficence often outweigh a patient’s autonomy and a physician may be justified in asserting hard paternalism to ensure the best outcome for a patient and his family.
I’d like to define “prima facie” and its application to your discussion.
What does it Mean to be “Prima Facie?:”
I consulted “Bioethics: Principles, Issues, and Cases,” composed by Lewis Vaughn, and found that autonomy is prima facie; it can sometimes be overridden by considerations that seem more important or compelling—considerations that philosophers and other thinkers have formulated as principles of autonomy restriction (Vaughn 9). Incompetent patients cannot make free choices about their health care because they are not rationally able to weigh up decisions and are incapable of forming unimpaired and rational judgments concerning the consequences. In cases such as these (especially where death is likely), a greater weight must therefore be placed on the principles of nonmaleficence and beneficence.
Works Cited
Vaughn, Lewis. Bioethics: Principles, Issues, and Cases. New York: Oxford University Press, 2010. Print.
Marianna,
I really like the way you approached this dilemma with your argument. In past discussion of autonomy, we have not taken familial influence into account too much, and I think you do a really good job of pointing out that is it something that almost everyone takes into account. Just as you said, it is very important to recognize that a family does strongly influence a patient’s decision making, especially if that patient is still dependent on the family.
A patient who evaluated these “external factors” in their medical treatment choices seems as if they are doing the right thing, but in many cases, they could actually be hurting themselves more than helping. If we allow a physician to practice hard paternalism and step in when a patient is making a choice that could hurt him/her or even potentially end their life, then we should allow a physician to step in when a patient and family are collectively making the “wrong” decision. Holding a physician accountable for a patients harmful medical choices, in cases where it is applicable, means that we must also hold him/her accountable when the family is involved.
In the case in question, the right thing for the doctor to do here is to not only heavily recommend that the stroke patient be given professional home healthcare, but do actually act on that decision. Not acting on this could lead to the harm of both the husband and the wife and though there is no solid proof that this is possible, in his experience, the physician knows this is what’s best for everyone involved. Hard paternalism brings up a lot of discussions about disrespecting autonomy, but it is important to consider the well-being of the patient and the family when considering whether or not delegitimizing a patient’s autonomy is justified; especially since this brings about a slippery slope of disrespecting patient’s rights. The doctor may not always “know best” but it is more than likely that they know the best decision regard whether a patient is right or wrong in their choices regarding their medical choices.
Works Cited:
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009, 2013. Print.
Mappes, T. A. & Zembaty, J. S. “Patient Choices, Family Interests, and Physician Obligations.” Kennedy Institute of Ethics Journal, vol. 4 no. 1, 1994, pp. 27-46. Project MUSE
Hello Marriana,
You bring up many great points about family involvement in patient decision making. I think this is a very tricky topic when trying to maintain full patient autonomy because as you pointed out, patients typically consider the external consequences of their decisions. Because of this, it is really difficult to have a patient make a decision that is 100% based off of their actual desires.
In this particular case, I believe that the doctor should act in the best interests of the patient. Sometimes, a patient ma desire something that is not actually the best decision for them. Although the patient is competent, it is the physicians duty to do what is best for the patient. Perhaps different tactics can be used in cases such as these where doctor’s believe another option may be best for the patient. It’s important for the doctor to present all of the facts while trying to avoid bias. I believe the doctor should also explain why he or she believes one option may be better than another.
Marianna, great points about consideration of family. I was wondering–what are your thoughts on how family and/or patient should consider QALY when making “right” or “wrong” decisions. Much of class discussion and blog posts have touched on the principle of autonomy and other more qualitative principles. Now bringing in more quantitative, utilitarian methods of consideration such as discounted future earnings (DFE) and willingness to pay (WTP), how do we reconcile our decisions now?