words (Max 2000 words)
– It must include a thesis statement and an argument defending it
– Define all key terms
– In defending your thesis, acknowledge and attempt to rebut two counter-arguments to the position you take
– The essay must be typed in double-spaced
– Include the cited papers as a download link or PDF format
The essay must address all the following questions: Is a paternalistic approach to truth-telling in medicine ever justified? If so, then how would you ethically defend it and what practices would it involve? If not, then how would you ethically defend an approach that prioritizes autonomy? How would that approach differ in practice from a paternalistic one? Use case examples to illustrate your reasoning.
Is a Paternalistic Approach to Truth-Telling in Medicine Ever Justified?
Truth-telling is a very vital virtue for any health care professional. It promotes trust between a doctor and a patient. There are various approached to truth-telling, and the emphasis is in most cases on paternalism versus autonomy (Hebert, 2010). According to Herbert (2010), truth-telling in medicine as the attitude and practice of being honest and open with patients. It is the genuineness that exists between the patient and the healthcare professional that acts as a foundation of trust. Views on truth-telling regarding disclosure of patients’ information has gradually changed in the recent literature (Rodriguez-Osorio & Dominguez-Cherit, 2008; Kling, 2012). This change is mainly through a gradual shift from the paternalistic approach where the doctor is presumed to know best to that of giving more preference to patients’ autonomy in decision making (Rodriguez-Osorio & Dominguez-Cherit, 2008). Citing research findings building on various philosophical arguments, this paper holds that a paternalistic approach to truth-telling in medicine is never justified.
Medical paternalism emphasizes the medical practitioner’s views at the expense of patient autonomy in decision making. Although a shared decision-making approach is common, it is not as universally favored as the paternalistic approach as far as real-world practices are concerned. Many patients would rather leave the doctor alone to determine his or her fate. For patients who are critically ill, the involvement of close family members becomes an integral part of the decision making process.
There is considerable ethical conflict in regards to whether medical practitioners should adopt a paternalistic approach. The conflict arises because the doctor has to strike a balance between the need to foster patient autonomy and to act in the best interest of that patient’s needs. By choosing a paternalistic approach, a doctor overrides the views of his or her patients and ends up doing what he or she thinks best serves the patient’s interests. The philosophy that informs this approach is based on the view that the physician can help a patient to make some of the choices he would make for himself if only he was in the right frame of mind. This interference in a patient’s decision making is justified by the argument that it is legitimate for the physician to interfere if he is convinced that the decision will facilitate the achievement of the outcomes the patient wants.
There are different levels to which medical practitioners can adopt a paternalistic approach, although there is no justification for any of them. For instance, some paternalists take over the right to mandate certain actions and to ban others. To justify this approach, doctors argue that patients can at times be confused, uninformed, and/or mistaken about the ends being achieved and the most effective means of achieving those ends. However, it is morally wrong for a doctor or the state to deny patient freedom of choice simply because of assumptions regarding his psychological state. More profoundly, such an approach can easily be abused by doctors who take advantage of the patient’s mental and psychological state to make choices that promote his personal interest rather than that of the patient.
In contrast, other paternalists only go as far as to skew the patient’s decisions without significantly interfering without greatly curtailing their freedom of choice. Doctors may also exhibit variation in the way they exhibit paternalism based on the extent to which they are willing to acquiesce to the patient’s decisions. Ideally, the decision that is arrived at should be an outcome of a discussion between the physician and the patient. However, as a professional, the physician may be privy to some undisclosed information that informs his non-acquiescence to some of the patient’s demands. Many doctors choose to go with passive paternalism, whereby they do not object to the patients’ demands but they refuse to implement them. This happens because doctors find it easier to justify passive paternalism compared to active paternalism. In both cases, however, the patient’s freedom of choice is at stake and the medical fraternity may be said to have disrespected the patient’s autonomy.
According to the British Medical Association (2004), paternalism can only be justified if the patient is exposed to serious health problems that can be prevented through paternalistic action. In other words, the benefits that are expected to be achieved through the paternalistic action should outweigh the risks posed to the patient. Even in such a situation, medical practitioners should choose the alternative that least restricts the patient’s autonomy (British Medical Association, 2004). To this extent, the debate may have shifted from paternalism-autonomy issues to that of actual medical practitioner’s undertaking of his professional obligations. In other words, a doctor may not claim to have found justification for paternalism if he was merely fulfilling the obligation of helping the patient out of a dire medical emergency during which time the patient was not in a position to make certain decisions. As soon as the patient is out of danger and the significant risk has been mitigated, his autonomy should be fully restored.
A recent study showed that 62 percent of Americans prefer shared decision making, while 28 percent would opt for an informed approach (Rodriguez-Osorio & Dominguez-Cherit, 2008). Only 9 percent said they would prefer paternalism. Another study showed that 96 percent of respondents preferred to be asked about their opinions and to be offered a list of available choices from which they can make a decision (Rodriguez-Osorio & Dominguez-Cherit, 2008). These findings indicate that the health care professional is obligated to offer professional advice but not to adopt a paternalistic approach, whereby he thinks that his opinion is the one that will best serve the patient’s interests.
There are many situations where doctors are influenced by circumstances to adopt paternalism in their interactions with patients. For example, a patient may be undecided and ambivalent about the right decision to make. In fact, some patients may be surprised that the physician is requesting for their opinion. In such situations, the physician must bear the burden of explaining to the patient the importance of seeking his views regarding the next course of action in the treatment process. Since patients’ expectations of deprivation particularly in terms of autonomy arise due to ignorance, medical professionals should never use their patients’ gullibility as a justification for using the paternalistic approach.
Patient’s preferences tend to vary significantly as far as the choice between autonomy and paternalism is concerned. Some patients expect to be fully informed about their health condition and the treatment options available. Others believe that it is upon the health care professional to make a diagnosis and commence with treatment without necessarily taking some time to find out what the patient’s views are. Similarly, the use of paternalism is strongly predicted by a wide range of factors, such as age, level of education, and culture. In many cases, the ubiquitous nature of these variables makes it seem as if paternalism offers the best framework for doctor-patient interaction. On the contrary, these factors can never negate the need for autonomy on the part of the patient, particularly in light of the reality that some unscrupulous medical professionals often take advantage of patients based on their age and level of education.
Autonomy in decision making can benefit patients because it frees them from controlling interferences by medical practitioners and from the various personal limitations that may inhibit adequate understanding. Within the realm of the medical profession, respect for the patient’s autonomy is a fundamental ethical principle. It is in the pursuit of this principle that the idea of informed consent was born. Research has shown that quality of life, as well as psychological and physical health, improves significantly whenever a patient is allowed to exercise a reasonable degree of autonomy.
An approach that emphasized autonomy differs from one that emphasizes paternalism in the sense that the former gives the patient the right to information as well as protection against practices that inhibit his understanding of his health situations and available choices (Kling, 2012). For example, a doctor who fails to tell the truth regarding a patient’s health condition in terms of the available treatment options and their outcomes is inhibiting that patient’s autonomy; failure, to tell the truth, is indeed one of the medical attitudes that have traditionally promoted paternalism (President’s Commission for the Study of Ethical Problems in Medicine, 1982). If a patient suffers from cancer, for example, a patient must be in a position to choose his most preferred treatment procedure from a list of available treatments.
Unfortunately, paternalism comes in the way due to both internal factors such as the patient’s lack of understanding of the various treatment options and external factors such as the use of force, manipulation, or coercion by both medical practitioners and close family members (Rodriguez-Osorio & Dominguez-Cherit, 2008). Doctors are directed by the fundamental ethical principles governing their profession to provide accurate information to patients. Informed consent promotes the idea that providing accurate and relevant information empowers a patient to make decisions that they could otherwise not have made if they were not informed about the exact nature of their health condition.
There are many cases in the recent past where physicians’ refusal to disclose a condition to a patient have been reported. These cases are reflective of old medical attitudes that seem to be taking too long to die even in the current environment where a paternalistic approach to truth-telling is never justifiable. For example, during the 1990s, there was an ongoing court case in Ontario, Canada, whereby a neurologist had failed to disclose to a family that one of their members was suffering from dementia following a suspected diagnosis of the disease during the early 1980s (Hebert, 2010). By failing to reveal the diagnosis for over seven years, the neurologist was simply living up to old medical attitudes, whereby medical practitioners refused to reveal suspected diagnoses of diseases that have little effective treatment such as dementia. The matter was settled in court, which failed to fault the doctor for failing to disclose the diagnosis, arguing that the diagnosis was speculative.
In conclusion, a paternalistic approach to truth-telling in medicine is never justified. The idea of informed consent, which is a fundamental ethical principle governing the medical profession, is designed to protect patients against paternalistic physicians. The best-case scenario is one where a physician explains all the available treatment options and gives the patient (or his family members) to make a decision. Whenever patients are accorded autonomy in decision making by being given accurate information and protected against various personal limitations that may inhibit adequate understanding of their condition, rapid improvements are bound to occur in terms of physical health, psychological wellbeing, and quality of life.
British Medical Association. (2004). Medical Ethics Today: The BMA’s Handbook of Ethics and Law, Third Edition. London: BMJ Publishing Group.
Hebert, P. (2010). Disclosure: Ethical and policy considerations. Canada: Commission of Inquiry on Hormone Receptor Testing.
Kling, S. (2012). Truth-telling in clinical practice: Is it ever ok to lie to patients? Current Allergy & Clinical Immunology, 25(1), 34-36.
President’s Commission for the Study of Ethical Problems in Medicine. (1982). Summaries of the reports from the president’s commission for the study of ethical problems in medicine and biomedical and behavioral research. Washington, DC: U.S. Government Printing Office.
Rodriguez-Osorio, C. & Dominguez-Cherit, G. (2008). Medical decision making: Paternalism versus patient-centered (autonomous) care. Current Opinion in Critical Care, 2(62), 708–713.