The concept of autonomy is central to ethics in general and medical ethics in particular. The preservation of autonomy allows for self-determination and liberty. The promotion of autonomy in moral choice can be contrasted with the effects of a paternalistic approach to medicine, which often amounts to ‘a rather arrogant assumption that one knows best’ on the part of doctors (Campbell Gillet and Jones 2005 P.3).
Ethical approaches to medicine relate to power because there can often be power imbalances between health professionals and patients. The doctor-patient relationship is therefore an important instance of a relationship between individuals which needs to be governed by ethical behaviour. Patients, particularly those in hospitals, can be at a disadvantage if a disparity exists between them and their doctors in terms of education, information about their condition and the treatment options for it. This is especially relevant when the patient’s condition makes them vulnerable. Health professionals should be mindful of this and seek to redress the imbalance.
The problem of paternalism is often expressed in terms of a conflict between the principles of autonomy and beneficence (Hope Savulescu and Hendrick 2008 P.41) because paternalistic doctors may intend to act in the patient’s best interests without fully considering how their evaluation of those best interests may be modified by a fuller understanding of the patient’s views.
The paternalistic approach can be criticised in several ways. Firstly, Mill’s defence of libertarian principles can definitely be applied to this issue:
‘…the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant’ (Mill 1859 in Hope et al 2008 P.41).
The approach of Mill seriously undermines the paternalistic defence of acting in a person’s best interests without taking into account their wishes, feelings, beliefs and values on the matter at stake.
Furthermore, good intentions aside, Berlin indicates that the paternalistic approach to medicine could be subject to abuse of the power entrusted to physicians by the unscrupulous (Hope et al 2008 P.41). It could be ‘too easy and dangerous’ for the powerful to dictate the chosen course of action, on the grounds that they have a more sophisticated understanding of what opposing people really need or want than those people themselves do (Hope et al 2008 P.41). Paternalism is problematic because the definition of a patient’s best interests used by a paternalistic approach is too narrow, because ‘[s]uch best interests are not determined by the medical facts alone’ (Hope et al 2008 P.61); the patient’s views and beliefs matter too.
A traditional paternalistic approach does not sit well with the “patient-centred’ medicine’ now practised by modern clinicians (Hope et al 2008 P.40). This is because the modern approach has been informed by the principle of autonomy. However, there are alternatives to the paternalistic approach. Some of the alternatives have been more influential in the development of modern medical practice. A brief description will help to put the approaches I have been discussing in context and elucidate the issues at hand. Emanuel and Emanuel contrast the paternalistic approach with the following alternative models for doctor-patient relationships: informative, interpretive and deliberative approaches (Hope et al 2008 P.61).
The informative model treats the patient as a consumer. This recognises the relevance of patient choice but reduces the role of the doctor to a technician providing the chosen service (Hope et al 2008 P.63). The interpretive model and the deliberative model provide better alternatives to these unsatisfactory approaches. Both promote ‘shared decision making’ and ‘negotiation’ between doctor and patient (Hope et al 2008 P.64). The interpretive model portrays the doctor as a counsellor who will inform the patient and interpret relevant values to implement the chosen treatment (Hope et al 2008 P.62). The deliberative model portrays the doctor as a teacher and further suggests that it is appropriate for the doctor to challenge the patient’s values (Hope et al 2008 P.62). In my view, the interpretive model is the most appropriate.
Likewise, Campbell et al explore the idea of a covenant relationship between doctor and patient, ‘a promise to show active concern for the welfare of the other’ which also recognises the vocation many doctors have for their profession (2005 P.22-3). A model of partnership is a more secular version of this ideal for doctor-patient relationships which most successfully avoids the dangers of paternalism. This requires honesty and good communication between doctor and patient.
The Mental Capacity Act 2005 (MCA) is also relevant to these issues. The MCA demonstrates a shift in the approach to medicine, because the concept of autonomy is ‘the philosophical underpinning to the idea of capacity to consent’ (to medical treatment) (Hope et al 2008 P.41). The MCA begins with presumption of capacity of adults and the competent patient’s right to refuse treatment (Jackson 2009 P.226, 216).
Some doctors find applying the MCA difficult because of entrenched paternalistic attitudes which threaten to undermine the MCA by assuming that any person who makes a decision they deem irrational must be incompetent, contrary to the key principles of the act and without reference to the functional test for mental capacity, which is based on decision making ability (Jackson 2009 P.227-228).
I hope I have shown that ‘…the old paternalistic attitude in which patients were kept in virtual ignorance must be rejected’ (Campbell Gillet and Jones 2005 P.26). Rejecting a paternalistic approach to medicine can lead to the redressing of an often unequal power balance, and the empowerment of patients who could otherwise be vulnerable, thus enabling self determination and patient-centred decision making wherever possible.
Rachel Warren is a Masters student in Medical Ethics and Law at Kings College London
Jackson. E, 2009, Medical Law: Text, Cases, and Materials Oxford: OUP.
Campbell. A, Gillet. G and Jones. G, 2005, Medical Ethics (Fourth Edition) Oxford: OUP.
Hope. T, Savulescu. J and Hendrick. J, 2008, Medical Ethics and Law: The Core Curriculum (Second Edition) Edinburgh: Churchill Livingstone Elsevier.