J Med Ethics: first published as 10.1136/jme.11.4.184 on 1 December 1985. Downloaded from Joumal ofmedical ethics, 1985, 11, 184-187

Paternalism modernised

Gary B Weiss University ofTexas

Author's abstract This article discusses the concept of paternalism, The practice ofpaternalism has changed along with reviews the changes in its practice, and contrasts this developments in medicine, philosophy, law, sociology and modern form of paternalism with patient autonomy. psychology. Physicians have learned thatapatient's values Although a new term might be considered to reflect are a factor in determining what is bestfor that patient. this modern approach, the word paternalism captures Modernpaternalism continues to beguided by theprinciple the notion of benefit to the patient as the most that the physician decides what is bestfor the patient and important part of the doctor-patient relationship. pursues thatcourse ofaction, taking into account the values Although pejorative associations are attached to this and interests ofthe patient. In the autonomy model ofthe term, (apparently as a consequence of stereotyped doctor-patient relationship, patient values are decisive. In images), paternalism may be more ethically persuasive the paternalistic model, they are but one among several than the current philosophical literature suggests. factors the physician must consider in making a medical decision. Although diffwcult to practise because of History copyright. limitations in empathising with another person, modern Paternalism has been defined as 'interference with a paternalism remains a way to achieve maximum patient person's liberty of action justified by reasons referring benefit. exclusively to the welfare, good, happiness, needs, interests or values of the person being coerced' (1). Medical practice has changed greatly in the past 40 Medical paternalism is defined similarly as years. Many previously untreatable illnesses interference by the physician with the patient's (especially infections and cancer) can now be managed

freedom of action, justified on the grounds of the http://jme.bmj.com/ effectively and new technological marvels can sustain patient's best interests. life. Physicians are expected to be aware of these new Examples ofpaternalism are easy to find early in the developments, being obliged to take continuing oncology literature. The results of a survey reported medical education courses, and they are subject to in 1961 indicated that almost 90 per cent ofphysicians penalties in malpractice suits under the assumption withheld diagnostic information from cancer patients that a competent physician keeps up to date. The because of the possibility that the knowledge would physician who still treats syphilis with arsenicals, for have an adverse effect on the patients (2), and more example, would be judged incompetent, even though specifically, surgeons have suggested that patients not on September 26, 2021 by guest. Protected this was once standard therapy. be informed of Parallel to new scientific achievements, notable the nature of seriously mutilating developments have taken place in clinical ethics procedures, such as hemipelvectomy, until in immediately before the operation because the patients, because of changes clinical, philosophical, legal, with more time for consideration, might refuse a sociological, and psychological practice. Paternalistic potentially life-saving procedure (3). physicians hold firm to the principle that they should Although such paternalistic methods were act to bring about maximum benefit for the patient, commonly accepted in the past, they do not reflect even at the expense of the patient's autonomy, current practice. Nevertheless, they are offered as although these recent ethical developments have been examples of present-day paternalism, which is then responsible for modifications in paternalistic style and criticised in much of the current philosophy literature practice in ways that are almost as great as the changes (4). A recent survey, however, showed that 97 per cent in clinical practice. The current criticisms of of physicians preferred to tell cancer patients their paternalism, however, describe an old model and use diagnosis (5) and hemipelvectomy for osteosarcoma is outdated examples; many of these transgressions are now performed much less frequently in favour oflimb- no longer common. sparing procedures. Criticisms based on the assumption that paternalistic physicians do not inform Keywords cancer patients about their diagnoses (6) are largely Paternalism; patient autonomy; beneficence; medical ethics. outdated. Although these changes might be J Med Ethics: first published as 10.1136/jme.11.4.184 on 1 December 1985. Downloaded from Paternalism modernised 185 interpreted as a swing away from paternalism towards Many current treatments require the patient's active patient autonomy, they can also be viewed as a co-operation. To ensure that the patient performs continuation of the practice of providing what breathing exercises postoperatively, returns to the physicians believe to be best for the patient in the light hospital if fever develops after chemotherapy, or of new knowledge. completes a course of oral antibiotics, the physician Criticisms of paternalism generally follow one of must provide him or her with sufficient information to several lines. The argument most often advanced understand why co-operation is essential. Thus, claims that physicians cannot and do not know enough medical changes have modified the concept of what is about their patients' wants, needs, interests, hopes and best for a patient and have made it necessary actively to fears to make decisions for them (6). Modern enroll the patient in his care. physicians themselves, however, agree that this barrier Society has experienced the same changes that affect exists and, whatever their philosophical position, the practice of paternalistic physicians. Civil rights, constantly strive to improve communication with their woman's equality movements, and consumerism have patients. Another argument often used is that the all emphasised the desire ofpeople to be treated as self- physician's own motives and self-interest may come determining agents. Well-informed patients into conflict with the best interests of the patient (7), themselves may now suggest other treatment and many anecdotal examples have been given to possibilities or may at least express their opinions as to establish this point (8). These anecdotes serve merely how they would like to be treated. As a consequence of to inflame the reader's feelings. The observation that patients demanding a more active role in their own some physicians have weaknesses in their character can care, physicians have become aware that patients may be used to condemn their behaviour but has no refuse necessary treatment when they feel that their relevance to paternalism. If selfish acts are justified on prerogatives are being usurped. This risk must be the basis of paternalism, then rhetorical subterfuge considered in all medical decisions. may be added to the charge of selfishness, but Psychologists and sociologists have demonstrated paternalism itself is not at fault. The most important that benefits accrue when patients are involved in their criticisms against paternalism focus on the question of own care (12). Ensuring that patients are informed whether the principle-of respect of person has prioritv provides protection against untoward consequences.copyright. over the principle of beneficence (9, 10). This Using surveys, psychologists have indicated what argument and the history of the general acceptance of patients want from their physicians; this information autonomy over beneficence are beyond the scope of enables physicians to modify their behaviour so as to this paper. satisfy their patients. Further, studies are beginning to These criticisms must be reviewed against the examine various behavioural questions regarding the background of changes that have occurred in physician-patient relationship. Well-designed studies

paternalistic behaviour because of the changes in are needed to answer the question of whether http://jme.bmj.com/ medicine, society, sociological studies, law, and ethics informing cancer patients of their diagnosis leads to and in response to these criticisms. All ofthese changes suicide or other serious harm so that the decision to tell increase the probability of achieving the purpose of them can be based on information rather than paternalism (that is, doing what is best for the patient). speculation. Numerous decisions by the courts and legislature have caused physicians to modify their behaviour. The changing practice of medicine Massachusetts (13) and California (14) now have laws Changes in the science of medicine have modified requiring patients with breast cancer to be provided on September 26, 2021 by guest. Protected paternalism in several ways. The availability of more with 'complete information on all alternative than one effective therapy (as the choice between treatments which are medically viable' (13). A number radiation therapy or surgery for early carcinoma of the of cases (15) have affirmed the obligation to take a larynx) dictates that therapeutic decisions be made patient's views into account in making decisions, and with consideration for the special circumstances of the have reminded physicians about the controversial patient (11). For example, the physician might choose nature ofwhat is best for a patient. The law has also set to treat a salesman with radiotherapy to spare his voice, limits on paternalistic actions; physicians generally and to treat a cook with surgery to spare the ability to may not initiate treatment without the patient's taste. Also, technological advances, such as the artificial informed consent. Finally, the case of Truman v heart, bone marrow transplantation, and renal dialysis, Thomas (16), in which a physician lost a suit brought have caused physicians to confront a number ofethical by the family of a patient who died of cervical cancer issues and, particularly, to reassess what is best for a after refusing a Pap test, has defined an obligation that patient. Finally, with life support available for physicians warn of the dangers of refusing terminal patients, the value of sustaining life as the recommended diagnostic procedures as one of the ultimate good has rightly been questioned. These necessary elements in proper medical care. changes mean that what is 'best' for the patient varies The recent emphasis on ethics has stimulated from patient to patient - in part, because of the physicians to explore the ramifications oftheir actions. different values held by each patient. They may consult the literature when they encounter J Med Ethics: first published as 10.1136/jme.11.4.184 on 1 December 1985. Downloaded from 186 Gary B Weiss difficult or unusual ethical problems in the same lessened for the patient's ultimate benefit, should not manner as when they confront unfamiliar diseases. be confused with authoritarianism, where this freedom Earlier criticisms of paternalism questioned the is lessened for the physician's power. doctor's motives. Now, physicians try to be aware of In most circumstances, the results of treatment will their motivations as well as those of their patients, and be similar for either the modern paternalism or the since different physicians and different patients may patient-autonomy model because both physician and hold disparate views of what is best, the modern patient want what is best for the patient. In situations paternalistic physicians has well learned the need to where options appear equal to the physician, no reason explore the differences among individual patients. exists to deny the patient the decision-making if he wants it. So, we must ask, under what circumstances, Modern paternalism if any, does modern paternalism offer advantages to How does today's paternalistic physician operate while the competent adult patient? First, many patients being influenced by so many forces? The guiding choose immediate gratification over possible long-term principle of modern paternalism remains that the benefits, even though they realise that the latter course physician decides what is best for the patient and tries is better for them. For example, a young man with to follow that course of action. The notion that doing curable testicular cancer may wish to avoid the what is best for the patient can be determined from temporary but severe nausea produced by only the physician's values is antiquated - an approach chemotherapy. This situation justifies and even as ineffective as arsenicals in syphilis. A more requires the physician's encouraging, or if necessary, homogeneous culture in the past allowed physicians to coercing the patient to complete the therapy. assume that they shared values with their patients, but Second, formal decision-analysis is unfamiliar to in a pluralistic society, the patients' views can never be most patients, whereas physicians are trained in assumed. Today's physician must ascertain the values problem-solving. Thus, armed with adequate and interests of the patient. Omission of this step is a information about a patient's values, the physician may betrayal of the fundamental principles underlying be in a better position to decide effectively what is best for the patient than the patient even if he has been modern paternalism. copyright. The simplest approach to learning the patient's informed of all the medical information and then values is to ask him what he wants. To expand this makes his own decision. Although understanding a information, general discussions with the patient, or patient and his values fully may be difficult (and perhaps with friends and family of the patient, will be of help. impossible) for the physician, patients may find This thoughtful probing has always been an important understanding either the scientific basis for their part ofgood medical care (17) and is mandatory for the treatment or the underlying motivations that influence modern paternalist. This information is now used to their own decisions equally difficult. Finally, the determine what is best for the patient in addition to physician is likely to be more objective about the http://jme.bmj.com/ establishing rapport, making a diagnosis, improving patient than the patient will be about himself. communication, and offering support. Discussions Practising modern paternalism is difficult. The about cardiopulmonary resuscitation with all patients problems stem not from restrictions in the law or from who are seriously ill permit the doctor to determine refusal by patients but from the great difficulty in what a patient prefers; such discussions have become empathising with another person to the extent ofsafely routine at many hospitals (18). determining his best interests. Empathy or good After determining what is best for the patient, the intentions alone are insufficient; the modern physician must implement the plan. Because active paternalistic physician must also have the medical on September 26, 2021 by guest. Protected patient participation produces better results, he will expertise to make the decision. Further, making usually inform or instruct the patient. His goal is to decisions is often more difficult than relinquishing the improve care rather than promote patient autonomy. decision-making to the patient. Finally, no matter how Gert and Culver (19) presented the case of a physician expert the physician is and how conscientious in his who acted paternalistically by confronting a patient paternalism, the results of treatment are not always who had breast cancer with the truth. predictable and for some patients may not prove If the patient will do better believing he is in control optimal. Of course, the physician must also be selfless the physician should encourage this belief and and not use the patient's 'best interests' as an excuse for indirectly facilitate the right choice ofaction. Usurping his own greed, egotism or laziness. a patient's autonomy merely to allow the physician to The concept of patient autonomy emphasises retain control represents authoritarianism, not procedure and the right of patients to decide for paternalism. Over 50 years ago, H L Mencken (20) themselves; modern paternalism emphasises outcome wrote that some physicians 'conceive it to be their duty and the principle of patients' best interests. An to force their advice upon everyone, including important difference between autonomy and especially those who don't want it. That duty . . . is paternalism is the weight given to patients' values. born of vanity, not of public spirit. The impulse Autonomy considers patient values as decisive. behind it is not altruism, but a mere yearning to run Modern paternalism considers these values as only one things'. Paternalism, in which a patient's freedom is factor among others weighed by the physician in J Med Ethics: first published as 10.1136/jme.11.4.184 on 1 December 1985. Downloaded from Paternalism modernised 187 making a decision. Each posture has advantages and (8) Kassirer J P. Adding insult to injury: usurping patients' disadvantages. Failure of either to work in some prerogatives. New Englandjournal ofmedicine 1983; 308: situations does not necessarily invalidate it for others. 898-901. Criticisms based on an antiquated image of the (9) Childress J F. Who should decide?: paternalism in health paternalistic physician, however, have no value. care. New York: Oxford University Press, 1982. to (10) Clements C D, Sider R C. Medical ethics' assault upon Paternalism needs be evaluated logically, and any medical values. Journal of the American Medical forceful critique must examine the practices and Association 1983; 250: 2011-2015. principles of modern paternalism. (11) McNeil B J, Weichselbaum R, Pauker S G. Speech and survival: tradeoffs between quality and quantity oflife in Gary B Weiss MD PhD is Clinical Associate Professor of laryngeal cancer. New Englandjournal ofmedicine 1981; Medicine and of Human Biological Chemistry and 305: 982-987. Genetics at the University of Texas Medical Branch at (12) Dodd M J. Measuring informational intervention for Galveston. chemotherapy knowledge and self-care behaviour. Research in nursing and health 1984; 7: 43-50. (13) Annas G J. Breast cancer: the treatment of choice. References Hastings Center report 1980; 10(2): 27-29. (14) Carter S K: The California breast cancer law and (1) Dworkin G. Paternalism. Monist 1972; 56: 64-84. government-mandated patient education. CA: a cancer (2) Oken D. What to tell cancer patients: a study ofmedical journalfor clinicians, 1982; 32: 173-176. attitudes. Journal of the American Medical Association (15) Gutheil T G, Appelbaum P S. Substituted judgment: 1961; 175: 1120-1128. best interests in disguise. Hastings Center report 1983; (3) Miller T R. One hundred cases of hemipelvectomy: a 13(3): 8-11. personal experience. Surgical clinics of North America (16) Gargaro W J. Cancer nursing and the law: informed 1974; 54: 905-913. refusal: part IV. Cancer nursing 1980; 3: 467-468. (4) Thomasma D C. Beyond medical paternalism and (17) Peabody F W. The care of the patient. Journal of the patient autonomy: a model of physician conscience for American Medical Association 1927; 88: 877-882. the physician-patient relationship. Annals of internal (18) Miles S H, Cranford R, Schultz A L. The do-not- medicine 1983; 98: 243-248. resuscitate order in a teaching hospital: considerations (5) Novack D H, Plumer R, Smith R L, Ochitill H, Morrow and a suggested policy. Annals ofinternal medicine 1982;copyright. G R, Bennett J M. Changes in physicians' attitudes 96: 660-664. toward telling the cancer patient. 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Institute news and notes Professor R B Welbourn, Emeritus Professor of Surgical Endocrinology, and Chairman of the Governing Body of the Institute of Medical Ethics on September 26, 2021 by guest. Protected has received an honorary DSc from the Queen's University of Belfast.