Tag Archives: autonomy

The “When” of Libertarian Paternalism

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The reading on “Libertarian Paternalism” takes a concept that has for years been seen in a negative light and gives it a positive spin (Thaler and Sunstein). When discussing the history of health care and public health in America especially, the concept of paternalism is typically thrown around in tones of disgust and shame. Authority figures in the realm of health aren’t qualified to decide what is best for us—only we are capable of making those decisions.

In our discussions surrounding informed consent and autonomy, we continuously mulled over whether or not health care professionals have the right to make decisions or even narrow down treatment options for patients. I have come to the conclusion that they largely do have this authority and duty. Though the model of the doctor/patient relationship could use some serious work, patients do not need to know about each option available to them; being informed is important, but doctors are capable of narrowing down treatment options without full patient partnership.

Thaler and Sunstein take this question of the morality of paternalism to a different level. They use examples of a less immediate nature such as retirement plans and cafeteria layouts to illustrate the unavoidable nature of paternalism and just how beneficial it can be, suggesting that we not focus on whether or not paternalism is right in certain cases but how to choose the best paternalistic options.

Though the examples they use are simple, I believe Thaler and Sunstein have a point regarding paternalism in public health. People will most often do what is best for themselves. Public health is the improvement and maintenance of the health of communities, not the individual—thus it is not beneficial to rely upon individuals to make effective decisions in public health.

What is interesting to me, though, is that this argument can then stand as a counterargument in the informed consent and autonomy debate. If individuals do what is in their own interests, isn’t it then moral to leave health care decisions fully up to them? It would seem that if one asked Thaler and Sunstein, the answer would be yes. However, although I am convinced of their argument for paternalism in public health, I believe libertarian paternalism can also be applied to treatment decisions in health care.

Individuals are—to an extent—capable of deciding what is best for them; but in the realm of health care, there is a lot of knowledge that professionals have access to that the average person does not. Even with thorough information—it is difficult for patients to make these sometimes life altering decisions. What is so wrong with a little libertarian paternalism? As Thaler and Sunstein mention in their essay, in everyday situations in which this type of paternalism is used, it is because the people do not want to undergo the hassle of making an initial decision themselves, or they feel as though they are not specialized enough in the matter to make the appropriate decision on their own.

Though I have never before viewed paternalism positively, I believe this essay makes a sound argument for it. This does not mean that paternalism is good; it just means that there are several situations in which it is conducive to efficiency and genuine well-being which should make it acceptable.

Thaler, Richard H., and Cass R. Sunstein. “Libertarian Paternalism.” Arguing About Bioethics (2003): loc.  10829-10968. Print.

The Weight of Paternalism on the Public Health Scale

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In Public Health Law In an Age of Terrorism: Rethinking Individual Rights and Common Goods, Gostin examines public health law and the deficiencies associated with the current policies. He claims that there has been little emphasis on modernizing the laws to accommodate the recent advances in public health and constitutional law (Gostin 374). “Reform of public health law is essential to ensure that public health agencies have clear missions and functions, stable sources of financing, adequate powers to avert or manage health threats, and restrains on powers to maintain respect for personal rights and liberties” (Gostin 374-375).

During his argument, he challenges critic’s concerns about personal libertarianism and the protection of personal rights in the event of a national wide medical emergency.  For Gostin, compulsory power is necessary for public health because the government has the right to prevent individuals from endangering others. “The state undoubtedly needs a certain amount of authority to protect the public’s health” (Gostin 381). This action obviously compromises the individual’s autonomy in certain situations and creates moral concerns for authorities.

In addition to his argument, I think it’s important for critics to recognize how these policies come into play and who writes them. As Americans, we have the civil liberty to vote for policy makers, state representatives and even the passage of certain laws. While the individual’s current right may be undermined at the time of an emergency, they have the capacity to exercise their personal liberty in voting for state representatives and legislative officials.

You cannot remove paternalism from public health. As Thaler and Sunstein have pointed out, “some kind of paternalism is likely whenever such institutions set out arrangements that will prevail unless people affirmatively choose otherwise” (Thaler and Sunstein 390). The public voted for such regulations and must comply with them accordingly. In the realm of public health policy we often forget where the law initially stems from. It’s the people.

As citizens, we have the ability to exercise our autonomy towards choosing which paternalistic approach we like the most; perhaps it’s the one that promotes the most personal freedom. Regardless of the policy outcome, paternalism and public health go hand in hand.

Sources:

Thaler, Richard H., Sunstein, Cass R. “Behavioral Economics, Public Policy, and Paternalism: Libertarian Paternalism.” Arguing About Bioethics. London: Routledge, 2012. 386-391. Print.

Gostin, L.O. “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common Goods.” Arguing About Bioethics. London: Routledge, 2012. 374-384. Print.

Public Health and Respect for Personal Autonomy

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Applying ethical principles to the medical field has proven complex, as highlighted by James Childress in his writings on the complexities of adhering to respect for personal autonomy.[1] The philosophical discipline of bioethics is not narrowly tied to medicine, but expands to cover medical anthropology, medical sociology, health politics, health economics, research, public health policy, and more.[2] Public health aims at improving the health of the community as a whole, and public health initiatives usually involve preventative measures that prolong life and promote health. Generally, public health policy concerns itself with health based on population-level health analysis.  Thus, how do ethical principles change when the policy is focused on net benefit for the community, instead of focusing on individual community members?

Concentration on the group needs and health leads to thinking that often forgets about individual rights, but ethical principles of the individual need to be remembered when applying public health policies. Historically, individual rights are becoming increasingly recognized, and in the medical field, consent is a twentieth-century phenomenon.[3] As medicine increasingly recognizes individual rights, it is a logical extension for public health as a discipline to acknowledge analogous rights.

In bioethics, consent is rooted in the ethical principle of respect for personal autonomy, but this principle is complex and limited in application. Childress in “The Place of Autonomy in Bioethics” presents the scope of applicability of the principle of autonomy in medicine. He argues that first and foremost respect for autonomy of persons differs from people who are not autonomous such as children (unspecified age range) and the insane. Also, respect for autonomy must coincide with other necessary ethical principles such as beneficence and care, and in certain circumstances, ethical principles can outweigh or override one another. Thus, under certain circumstances the principle of respect for personal autonomy may be infringed upon, and specifically, the realm of public health needs to consider if policies made for the benefit of the group reasonably infringe upon the personal autonomy of group members.

The political cartoon depicts the modern-day anti-vacccination “epidemic.” This so-called epidemic is happening parallel to increasing focus on individual rights. Our generation will have to consider how much public health can infringe upon personal autonomy of our society’s citizens. (Source: http://theweek.com/cartoons/index/228275/the-anti-vaccine-epidemic)

This past September, 750 students in Winston-Salem, NC faced suspension after not adhering to state vaccination policies for the Tdap vaccination that protects against tetanus, diphtheria and whooping cough or pertussis.[4] Cases of mandatory vaccinations represent paternalistic interventions where interference with an individual’s liberty may be justified by reasons such as welfare, happiness, values, interests, and needs of the person being coerced. Mandatory vaccination initiatives are public heath measures that override rights of respect for personal autonomy for the sake of containing and preventing infection and disease. In context to this case, paternalism functions off the principle of beneficence. Mandatory vaccinations highlight the conflicts between moral principles, and under these circumstances, I think beneficence overrides each group member’s autonomy. While privacy and confidentiality can still be protected, controlling the spread of disease and preventing illness in community members is a moral call to action for vaccination. While it may be easier to fully respect the autonomy of an individual patient than an entire population, public health policy still should not deprive individuals of their rights without thoughtful consideration. Following Childress’s logic, are all group members considered equally autonomous thus infringement upon personal autonomy is the same? Or, based on group status does infringement on personal autonomy have different implications? In modern times, awareness of personal rights is increasing within bounds; therefore, it is important for public health to grasp and debate these ethical concerns. A new interpretation could view mandatory consent as a prior consent based on group membership, and thus interference is the price of group membership.[5]  Such a viewpoint believes that the individual’s interests are still considered, but an individual is accepting his or her role as a group member. Future public health policies could work to understand the line between respect for personal autonomy and social responsibility, and from there, public health can define its realm of action and control.

Sources:

[1] Childress, J. F. “The Place of Autonomy in Bioethics”

[2] Benatar, D. Bioethics and health and human rights: a critical view. Journal of Medical Ethics. 2006 January; 32(1): 17-20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563274/

[3] Veatch, R. M. “Abandoning Informed Consent”

[4] http://www.journalnow.com/news/local/article_b770c0ca-2484-11e3-93a9-001a4bcf6878.html

[5] Hall, Spencer. Should public health respect autonomy? Journal of Medical Ethics. 1992. 18: 197-201.

Why is (Respect of) Autonomy Important?: Possible Cultural Preconceptions Surrounding the Argument for Autonomy

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When discussing biomedical ethics, we frequently favor the right of the patient to decide. This emphasis and respect for autonomy can overrule any number of other considerations. Therefore, I ask the following: Why is (respect of) autonomy important? A typical answer, and likely my own response, would include the importance of the individual’s right to make his/her own decisions. It is an exceedingly important component of any medical decision, and not to be taken lightly. The individual has final say because the body/mind in question is their own.

While reading J. F. Childress’ article “The Place of Autonomy in Bioethics”, I was struck by the potentially confounding factor of socioculturally different views on the importance of autonomy. As a product of American society, I have been raised to believe that the rights and privileges of the individual are paramount. Our culture and, indeed, most of Western thought, is centered on the idea that individuality (and the individual’s conception of that individuality) is to be encouraged. Given the dominance of Western thought in philosophical inquiry, particularly bioethical inquiry, it makes sense that a discussion of bioethics would take into consideration autonomy, the right of the individual to make his/her own decisions.

Free will is another Western presupposition that comes into play when discussing autonomy, the idea that we are the deciders of our own outcomes. Though I do not seek to undermine either of these ideas (free will and the importance of individuality), I think it is important to acknowledge and address the ways in which these ideas shape our dialogue. The reasoning behind the emphasis placed on autonomy is founded in the belief of both free will and individual importance. Should a society, religion, culture, etc. manifest a rejection of either of these principles, autonomy would, in that community, cease to be a worthwhile focus in bioethical conversation.

At the risk of bastardizing, oversimplifying, and/or misrepresenting my argument, I will lay out a general description of what I mean: If we reject the philosophical idea of free will, then our autonomous decisions (whether medical or not) become unimportant – free will is founded in self-determination and without it, predetermination negates the significance of choice. If we reject the sociocultural weight with which we measure individuality, if we cease to believe that the rights of the individual outweigh other considerations, then the value of the individual’s decision is called into question: if the individual is insignificant, why does their opinion and consequent decision matter?

Given that there exist many communities in the world in which one (or both) of these ideas is rejected, I believe reflection on the preconceived significance of free will and individuality under which we discuss autonomy is important to fully understand why our particular society and culture holds autonomy to be important. This type of reflection allows us to transcend our preconceived notions and the potential dangers that arise from not understanding or acknowledging our accepted cultural and philosophical biases.

In short, though I personally believe that a patient’s right to autonomy is exceedingly important, I must acknowledge that a) others- particularly those whose opinions have been shaped by different worldviews – may very well disagree with that opinion,  and b) my reasoning behind that opinion is founded in my own sociocultural and philosophical views on free will and the value of the individual.

Word count: 557

Works Cited:

Childress, James F. “The Place of Autonomy in Bioethics.” Arguing About Bioethics. By Stephen Holland. Hoboken: Taylor and Francis, 2013. Loc 8698-897. Kindle.

The Fight for Organ Donation

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The Uniform Anatomical Gift Act (UAGA) authorizes the indication, either in a will or on a driver’s license, of a desire to donate one’s organs or body post mortem to act as a legal document. It is crazy to think that any form of legal documentation not be honored and upheld in American society, but apparently it is not uncommon for doctors or even the Organ Procurement Organization (OPO) to allow the family to act against the expressed wishes of the deceased. According to the UAGA, if a person has indicated their preference to be an organ donor, legally, the family has no say in the matter. So, why is such a decision, one made autonomously and ethically accepted as to be respected, so easily overruled at times? D. W. Donovan, a chaplain and vice president for mission and spiritual care at Providence Regional Medical Center in Everett, WA, claims that it is common practice to grant families the ability override previous declarations made by the deceased and offers three reasons for this in his article Defending the Donor’s Decision.

Although a doctor or OPO official have no legal reason to honor or even consider a family’s request to override the wishes of the deceased in regards to donating their organs, Donovan points out that it “can often leave medical personnel caught in the middle of an emotionally charged event” and put them in an awkward position when confronted by an “angry family member who is strenuously opposed to donation” (1). A study conducted in 2001 indicated that only 8% of OPO’s were likely to procure the deceased’s organs if the next of kin objected (1). Respecting a family’s overriding wishes, spares the doctor and the family member’s emotional distress presented by the situation.

Refusing to appease a grieving family member’s desire to keep their deceased love one “whole” or in-tact can have negative repercussions on the health facilities and is another reason that Donovan offers as to why we give in to family member’s requests. Although supporting a person’s decision to be an organ donor is an act of respect for the patient’s autonomy, it can be perceived alternately by the public as an “invasion of privacy and bodily integrity” and can result in poor public perception of that medical facility which is something that doctor’s would obviously want to avoid.

The third reason Donovan offers is that many regard a person’s choice to be an organ donor to not be an authentic autonomous decision. Miller’s article (that we read the other day) listed 4 qualifications for a decision to be regarded as autonomous: free action, authenticity, effective deliberation, and moral reflection. The choice to become an organ donor or not is made by checking a box at the DMV that literally just asks you if you want to be an organ donor. There is no explanation of what that entails, how the process works, how the organs will be procured, etc. Surely Miller would say that this is not a truly autonomous decision. Without any information about risks, benefits or alternatives to consider, how can one actively participate in effective deliberation even if it is a choice free of coercion and true to one’s generous disposition?

Are these common arguments enough to grant a family paternalistic authority over the body of a deceased loved one? I think it’s important to realize that emotions over the loss of a loved one often cause family members to act/think irrationally which certainly should at least prompt discussion of its own to determine whether decisions made in such emotional states can even really be consented to as autonomous.

 

1. http://www.chausa.org/publications/health-progress/article/march-april-2008/defending-the-donor’s-decision

The Limits of Informed Consent

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The autonomy of the patient has triumphed, in legal terms at least. Doctors and health care personnel are legally required to disclose information about treatments to patients, and patients have the legal right to say “yes” or “no” to any treatment. But how practical is informed consent? The legal implementation of informed consent seems to be mostly a matter of filling out extra paperwork. So that seems practical enough. On the other hand, actually practicing the moral values behind informed consent is much more difficult.

We value the freedom to choose on so many levels. We have a right to choose as consumers, as voters, as citizens and as competent people in general – so then why not as patients? Of course patients should have a right to consider multiple opinions, assess alternative treatments, and then make a choice on their own. But in reality, a patient’s autonomy is highly limited. A lot of the limiting factors are neither inconsequential nor easily avoidable. In Barriers to informed consent, Lidz et al. outline how patient trust, physician expertise, acute illnesses, and complex medical systems make true informed consent difficult to achieve.

Are we morally obligated to try to overcome these obstacles? Or can they be viewed as the practical, real-world limits to our abstract ideals of patient autonomy? This question isn’t really about obstacles like access to healthcare or the complexity of the healthcare system. There’s no question that we should be trying to increase access to care and streamlining the system. The interesting obstacles are those that deal with the doctor-patient relationship. Should we be trying to change this relationship on a moral basis?

Let’s consider patient trust and physician expertise – both important obstacles to informed consent. Patients often don’t really want to make a decision based on what they know about their medical condition. They instead trust the physician enough to make such decisions for them. I see this as a clear act of autonomy. It’s a very rational choice to trust a trained professional’s informed decision over one’s own, likely less-informed decision. Ah but that’s where physicians have to make sure patients are fully and objectively informed, right?  Well even if a physician explains the relevant diagnosis and treatment to the patient in an easily comprehendible way, most patients will not know the essential mechanisms and pathology behind the physician’s decision. They’ll instead be given a simplified picture of a complex system – one that is inevitably going to be biased towards the physician’s decision anyway. We can’t blame physicians for such simplified, biased explanations any more than we can blame scientists for being biased towards one particular theory or paradigm. In the words of Galileo, “it is not within the power of the practitioners of demonstrative sciences to change opinion at will,” (p 125). They are compelled to believe what they believe by the power of reason.

All of this is not to say that the “informed” part of informed consent is irrelevant just because it is likely to have a bias. But maybe the information is, for practical considerations, less important than what we call patient trust – a form of rational consent.

Sources:

Galilei, Galileo, and Maurice A. Finocchiaro. The Essential Galileo. Indianapolis, IN: Hackett Pub., 2008. Print.

Charles W. Lidz, Ph.D., Alan Meisel, J.D., Marian Osterweis, Ph.D., Janice L. Holden, R.N., John H. Marx, Ph.D. and Mark R. Munetz, M.D. “Barriers to Informed Consent.” Arguing About Bioethics. Ed. Stephen Holland. London: Routledge, 2012. 93-104. Print.