Medical Paternalism or Patient Autonomy

A common and controversial issue facing many medical professionals is medical paternalism versus patient autonomy. At the heart of every practitioner/patient relationship is trust, and the duty to uphold the patient’s best interest both ethically and privately. These foundations seem basic on the surface, but underneath lies a much more complex issue. Medical paternalism can be defined as the intervening of a person’s decision making or actions for her own good.

Oftentimes, medical paternalism can be considered as interfering with the patient’s autonomy and right to make an intentional, uninfluenced decision regarding her own medical care. Such interference can come in the form of decisions regarding the patient’s physical or psychological care. However, there must be certain caveats in which medical paternalism is unavoidable, and therefore acceptable as an act done in the patient’s best interest, while still holding true to the clinician’s obligation to the patient. This type of paternalism is referred to as weak paternalism.

Vaughn brings up several cases in which minor children are subjected to the religious beliefs of parents and as a result are kept from receiving proper medical treatment that would save their lives. For instance, eleven year old Ian Landman who slipped into a diabetic coma and died. A six year old girl who was injured in a traffic accident and was given a lifesaving blood transfusion which was strictly forbidden by the religion of her parents.4 In both of these cases the children were subjected to beliefs in which they had no choice. Despite a parent’s right to make healthcare decisions regarding minor children, it is immoral to cause irreparable harm or death in the name of martyrdom to a child that does not have the capacity to make rational and informed decisions. In cases like this it is important for the practitioner to make ethically sound decisions regarding the care of her patients even if the parents do not agree.

Next, there is the issue of an untreatable patient whom through the insistence of her family or herself demands to be treated despite a grim prognosis. In a case where treatment would not improve the patient’s condition or even potentially hasten her death it would be immoral. A patient whom has just been given bad news in regards to her health may not have the capacity to think beyond her emotional state. The same can be said for family members who are facing the illness and death of a loved one. The treating physician would be remiss if she did not first suggest either time, or seeing a therapist before making any treatment decisions. Some may find that in a case such as this that the doctor was acting outside of her boundaries with the patient and not respecting her rights to make decisions. However, a consideration must be made for the patient’s diminished mental status after hearing bad news.

Furthermore, there are cases in which treatment may sustain life, but will not improve the quality of the patient’s life in any way. Consider the case of 85 year old Helga Wanglie who fell into a persistent vegetative state.5 Helga was provided with treatment 24 hours a day, but her condition could not be improved. Her doctors explained to her family that treatment should be stopped. In this instance, the patient would actually be better off being allowed to die, but her family strongly disagreed and held on to hope that her condition would improve. The physicians were accused of trying to play God, and a second group of physicians were called in to assess Helga’s condition.6 The physician’s responsibility to treat the patient without doing harm must be considered in cases such as Helga’s. It would be ethically unacceptable for a physician to allow treatment that only served to prolong suffering.

There are also instances in which a patient may not have the cognitive ability to make appropriate healthcare decisions due to diminished physical health, mental disabilities, depression, or addiction. Patients such as this cannot be expected to make decisions regarding their healthcare with any type of confidence.7 Here the practitioner’s responsibility would be to make decisions regarding treatment that would benefit and enhance the patient’s quality of life. If a patient does not have the capacity to understand what is in her best interest, then it stands to reason that her autonomy cannot in fact be violated. Autonomy can only really be violated if the patient is coerced, threatened or purposely impaired.

A particular hot button issue in recent times has been the anti-vaccination movement. Parents deciding not to vaccinate their children against long time eradicated diseases is causing a rise in instances of potentially life threatening, preventable disease. These parents believe that the risk to their children outweighs the benefits of the vaccine. Recent developments have been able to refute the thought that vaccines have serious disease causing side effects and that their benefits outweigh their risks. Doctors continuously continue to recommend not only routine vaccinations, but also flu vaccinations for children and adults. While the recommendation comes as a suggestion, it can still be considered a necessary form of paternalism. Schools take the issue of vaccinations even further by requiring them for enrollment. In instances where the greater majority of the people will benefit, medical weak-paternalism is and should be considered acceptable.

A less common issue is that of patient refusal. A completely able and cognizant patient may opt to refuse treatment based on what she believes to be an acceptable quality of life. This becomes a particularly difficult situation for a physician because not treating a patient could be considered doing harm which violates the principles of the physician/patient relationship. Vaughn uses the case of Elizabeth Bouvia to illustrate this issue. Elizabeth, a quadrapelegic from birth was both competent, and mentally able to make decisions regarding her care. Elizabeth was in pain, did not receive adequate care or support from her family and had no real means to support herself.8 Elizabeth fought for her right to be given pain medication while she slowly starved herself to death.

Her physician did not uphold her wish and said that he would feed her by force if necessary siting that the hospital staff would suffer, and that the perception of the handicapped would be damaged. Elizabeth eventually won her right to die through appeals and court hearings.9 This case would suggest that a patient’s right to refusal is simply an essential right that should be upheld. However, it also begs to question how far those rights should go. If a patient could be cured from an illness from simple noninvasive treatment, should she still be able to refuse without intervention? If treatment is simple, readily available, and non-life altering, then the patient should be considered unable to make rational decisions and be treated.

Finally, there’s the thought that no decisions are really made by patients without instance of some degree of medical paternalism. Doctors feel confident in their ability to successfully treat and diagnose their patients. With a diagnosis comes subtle cues regarding the best course of treatment. It would be nearly impossible for a doctor to not impart his own thoughts on the best mode of patient treatment. Given that thought it can be said that people never really make any decisions alone or based on feelings or thoughts that she solely feels and thinks. People constantly alter their own thoughts and feelings everyday just by coming into contact with other people. While their autonomy is not being violated, they are still being swayed without knowledge.

In conclusion, there are varying degrees of medical paternalism. Some which violate the patient’s rights to make decisions regarding her own care and some that can be considered necessary in order to protect, improve, or sustain the patient’s life, or the greater good of the majority. Weak paternalism must be considered acceptable as it does not violate patient rights and provides proper treatment while maintaining the clinician’s obligation to the patient.

References
Vaughn, L. (2013). Bioethics Principles, Issues, and Cases. New York: Oxford University Press.