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Paternalism Modernised 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
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