Victoria Hand
IDMD 101
Professor Emerson

Medical Paternalism – Discussion Summary

My presentation topic covered a two-part paper by ethics philosopher Daniel Groll, which discussed the definition and ethics of medical paternalism. The first half of Groll’s paper addressed the question “What does it mean to act paternalistically?” in a medical context. To do so, he streamlined the concept of paternalism into a concept called the beneficence account, which defines paternalism as when physicians act “only or overridingly out of concern for (the patient’s) good.” The second half of the paper asks when it is acceptable for a physician to act paternalistically. Groll introduces two principles, the beneficence principle and the autonomy principle. The beneficence principle states that physicians should act in ways that are ultimately beneficial for their patients, while the autonomy principle states that physicians should respect a patient’s right to make their own autonomous decisions. Groll concludes that if you undermine the autonomy principle in favor of the beneficence principle, you are violating a competent patient’s right to choose, making your paternalism problematic. However, if you act paternalistically without violating the autonomy principle (e.g. a surrogate decision maker making a decision for an incompetent patient), paternalism may be both justified and unproblematic. After the presentation, our class discussed two questions about the topic that I presented. Overall, I feel like we focused more on the concept of whether or not certain physician decisions were justifiable in favor of discussing the amorphous definition of paternalism itself. In addition, people tended to focus more on “black-and-white” responses – that an action is either justified in all cases, or it is never justified – which I believe does not appropriately encompass the complexity of the issue. In hindsight, I wish that I had moderated the discussion more closely so that I could have moved the conversation forward to further questions, which addressed less dichotomous scenarios and the definition of paternalism. 

Question 1 asked which is more important – respecting a patient’s autonomy or acting solely for a patient’s own good? I made this question as general as possible in order to spark a wide range of conversation. During the following debate, the main arguments for autonomy were as follows: A competent patient knows what’s best for themselves, a physician can’t be aware of all of the factors that go into autonomous patient decision making, and that allowing patient autonomy maximizes well-being because it fosters trust between patient and doctor. Arguments for the beneficence principle included: Some patient decisions can affect others (e.g. the choice not to get a vaccine can harm public health because others could be infected), and that surrogate decisions (such as parents making a decision for their children) can be a very grey area. In the latter scenario, it may sometimes be more ethical for physicians to make the decision to care for the child. Selene mentioned an example where a child had terrible seizures and needed brain surgery; the parents declined, and so the child died. This point led the discussion to parent-child decision making, where we discussed when doctors can step in if a parent is making an objectively poor medical decision for their child such as denying life-saving treatment. I noted that the class approached this problem in two different ways, and their side of the debate typically reflected either the biomedical or the biopsychosocial model. BM model debaters focused primarily on the biological health of the child. They said that parents should have less autonomy if a child is in danger, and that certain social values (such as religious beliefs) should be discarded in favor of saving a child’s life. BPS debaters tended to favor psychological and social factors, debating more about the importance of culture and disclosure; their arguments included that religions should be respected as it improves individual well-being, and that if a doctor gives patients “all the information” (however that may be defined), parents should have full autonomy even if the child is in danger. They also mentioned that BP model people are downplaying the potential risks and financial/social costs of certain medically beneficial treatments for children.

The second question asked how, if at all, patient autonomy affects patient well-being, and how that could play into medical decision-making when considering whether or not paternalism is justifiable. The class unanimously agreed that in the large majority of cases, prioritizing patient autonomy fosters trust between patient and physician and has a positive effect on well-being. This includes disclosing all relevant information about a patient’s treatment. They also said that a lack of autonomy will have a negative affect on the patient and can result in “stress”, “fear”, and a “lack of trust”. Then we moved on to discussing in which situations beneficence – in the context where it is paternalistic – may be justified. Some topics brought up for when beneficence may be justified include when a patient is harming others, having suicidal thoughts, or if they are addicted to drugs. We talked about whether or not patients could be considered competent in the last two cases – whether a patient is exercising will and whether or not their autonomy should be prioritized if their mental being is unhealthily altered. Most people said that in these cases patient autonomy should still be respected, but that other consultations (such as speaking to family and considering social and psychological factors) should be considered before deciding on the specifics of disclosure/treatment. The conversation then moved to whether or not religious beliefs should be respected in patient autonomy, and most people agreed that religious beliefs should be respected.

After reflecting on the class discussion, I have come to the conclusion that there are some specific class “trends” that limit meaningful debate. In particular, both sides of the different debated scenarios seemed to idolize physicians as the “autocrats of objectivity” (Hand, 2023). Most of us are seeking to enter medical school and become physicians, so it makes sense that we would be biased towards seeing physicians in a more positive light. However, it’s notable to mention that doctors aren’t always good people, and that it’s important to consider checks and balances when talking about the power physicians have instead of believing that physicians will always strive towards ethics, correctness, and moral good. The class also seemed less willing to talk about “greyer” topics that required non-dichotomous thinking. Most people wanted a “hard and fast rule” that applies to specific scenarios, and debated as to what that rule should be. In Groopman’s “How Doctors Think”, he discusses the decision-making capability of contemporary doctors, and mentions that they are being “condictioned to function” within a “strict binary framework”. In the future, I hope to make an effort to direct the discussion to more individual, subjective topics to discourage this sort of thinking during debate. Viewing this discussion from a moderator’s perspective with the goal of neutrally taking notes and asking questions helped me gain a valuable view on how our debates trend as a whole, and I aim to utilize what I’ve learned to facilitate a more meaningful and intellectual environment for everyone in the future.