Revisiting Medical Paternalism: Ethical Considerations in Healthcare Decision-making

Question

Task: Is medical paternalism always ethically wrong, or are there contexts where it can be justified? How does medical paternalism intersect with patient autonomy and shared decision-making in healthcare practices? What are the ethical implications of paternalistic actions by physicians in complex medical situations?

Answer

Self-opinion on the provided context

The debate linked to "medical paternalism" has gained a certain momentum in recent times as the ethicists have challenged the "traditional role" of healthcare physicians as concerned "decision-makers" for the patients. Ethicists have claimed that it is ethically not permitted for doctors or physicians to unilaterally make "treatment decisions" on behalf of the patients. Precisely, impose their viewpoints, values, and decisions in the overall treatment process (Schwartz, Robert, 1992.p.163). In a medical context, the term “autonomy” refers to the “patient's right” to initiate “informed decision-making” about their health, and treatment procedure considering their own beliefs, values, and preferences (Genuis, Quentin, 2021.p.3). The ethicists have argued that such “disservice” is generally done to the key essence of “patient autonomy” especially when the physicians override these decisions, even choices with their judgments.

The information obtained from a scholarly article namely "Autonomy, Futility, and the Limits of Medicine” has confirmed that the “ideal model of medical care” supports when the patient and the physician engage in an informed and collaborative decision-making process (Schwartz, Robert, 1992.p.160). The same has also shaped my viewpoint about this particular key context. In addition, the information available in this scholarly resource has acknowledged that the expertise of the healthcare professional is directly involved in instigating the healthcare journey of a patient. The term, “patient autonomy” not only values the individual rights of the patients but also leads to initiating “patient-centered care”. Referring to this information, I believe, it is highly significant to respect patients’ autonomy. Precisely, patients must be considered as “active participants” in initiating any vital healthcare decisions. As initially stated, it is a collective and collaborative effort between the patient and the physician that optimizes the overall healthcare journey.

Along with this, it is also relevant to reflect on the nuances in the context of “decision-making” in treatment procedures. In my opinion, physicians must act paternalistically in emergency cases, especially when the patient is hardly able to make any decisions. Precisely, a certain level of paternalism is essential in emergencies when a patient lacks the decision-making capacity (Hostiuc, Mihaela, et al., 2022.p.1278). Therefore, maintaining a proper balance between the physician's paternalistic approach and the patient’s autonomy ensures the overall well-being of the patient. The same can dedicate the ethical challenges identified in the context of treatment procedures linked to the "informed decision-making", paternalistic viewpoint of the physicians. Based on my understanding, such an evolving landscape related to “medical ethics” aims to encourage a gradual shift towards the patient-centric approach and shared decision-making in the healthcare domain.

Reflect on whether medical paternalism is always wrong

In accordance with the information stated in this paper, medical paternalism is not always wrong. Rather, discussion about the applicability of medical paternalism leads to multi-layered exposure referring to various factors. Precisely, in my opinion, medical paternalism is a complex concept and it generally depends on different factors including the nature of the patient's condition. In addition, it is also essential to evaluate the degree to which medical paternalism is exercised referring to the circumstantial impact. In general, “medical paternalism” refers to the “action of the physicians" related to decision-making on behalf of the patients. As initially stated, the ethicists have argued against this healthcare approach and have emphasized on the significance of respecting patient autonomy (Schwartz, Robert, 1992.p.159). The same is also been depicted in the particular article, i.e. "Autonomy, Futility, and the Limits of Medicine"

Still, there are some complex situations where the "inclusion of paternalistic approach” can be justified though autonomy is generally considered as an elementary ethical principle. According to the information available at reliable sources, patients may lack "decision-making capacity" in emergency situations. Considering the complexities and emergence of the situation, immediate medical action is required to be taken in order to prevent harm or preserve life. In those cases, the physicians or the doctors may need to initiate decision-making without having the explicit consent of the particular patient (Murea et al., 2021.p.800). This specific form of “medical paternalism” is generally accepted and it is ethically justifiable to some extent as it is hardly possible to obtain “informed consent” from the patient. Apart from that, there are also certain cases when the patients hardly have the ability or capacity to comprehend the overall implications of their decisions.

The same is certainly relevant in the context of mental illness. In general, the medical paternalism approach is considered as justified in order to provide life-saving treatment to a patient suffering from mental illness because the patient fails to initiate any decision-making and refuses to cooperate with the physicians if the patient is suffering for a prolonged period.

On the contrary, the emphasis must generally be on shared decision-making when the physicians collaborate with the patients and provide them with necessary information. Such a collaborative approach often optimizes the overall effectiveness of shared decision-making, especially in the context of non-emergency situations. Based on the information depicted in this paper, the appropriateness of “medical paternalism” is highly dependent on the specific medical contexts including the patient’s mental and physical health.

Critical evaluation of the paternalistic approach of physicians toward their patients

The "contemporary medical ethics" has strongly emphasized on the essentiality of patient autonomy. Still, there are some complicated medical situations in which a "paternalistic approach” can be ethically justifiable. As indicated in "Autonomy, Futility, and the Limits of Medicine"physicians need to act quickly in accordance with their judgment and expertise in critical moments, especially when it is hardly possible to obtain consent from the patient (Schwartz, Robert, 1992.p.161). As an example, if a patient is in a life-threatening condition or is unconscious, it is morally permissible to rely on a paternalistic approach in order to initiate life-saving interventions for prioritizing the welfare of the patient. Apart from that, if a patient lacks the capacity to initiate “informed decision making” due to cognitive impairments and mental health issues, a paternalistic approach is often practiced in order to ensure proper medical intervention. Referring to this context, the paternalistic approach of the physicians can be justified as this approach has been applied to protect vulnerable individuals from experiencing more severe conditions.

According to the information available at secondary sources, a patient who is dealing with severe depression refuses necessary psychiatric treatment in some cases. Referring to the severity of the clinical emergence, medical intervention can proceed by overlooking the patient's autonomy to some extent. The paternalistic approach of the physicians is justified as this approach is being practiced in order to prevent potential harm to the patient, especially any potential risks of suicide and self-harm. This is to be included in this context that the physicians must have a responsibility to offer proper guidance especially when the patients hardly have essential expertise to initiate informed choices. As an example, a physician needs to ensure a more directive role in initiating treatment decisions if a patient is suffering from a complex and rare medical condition.

In those cases, the paternalistic approach of the doctors or physicians ensures the patient receives the best possible healthcare available. As per the information depicted in the secondary sources, the critics have argued that the paternalistic approach of the physicians may undermine the patient's autonomy (Vogel et al., 2021.p.114420). Despite of this fact, the “paternalistic approach of the physicians” is aimed at safeguarding the well-being of the patient. The fundamental principle of autonomy generally assumes that individuals can initiate informed and rational decision-making, but such an assumption is not completely true referring to all complicated medical scenarios. Eventually, the paternalistic approach of the doctors or physicians has become ethically permissible if it acts as a “protective measure" for patients who are incapable of any autonomous decision-making or vulnerable to some extent.

Despite of all the medical contexts stated in this paper, shared decision-making is often prioritized over the “paternalism approach of the physicians” (Murea et al., 2021.p.801). Even, patients are encouraged to provide their consent as per their expertise and understanding as well. In this context, it is highly relevant to state that ethical considerations generally extend to contextual and cultural factors. Different cultures may have different attitudes towards decision-making and autonomy in healthcare. The opinion or viewpoint of the patients may also differ from the physician’s point of view in some cases. In addition, sensitivity to various cultural norms is necessary in determining the applicability and appropriateness of paternalistic actions. The same enables to recognize what is ethically more acceptable in one particular cultural context in comparison to the others. In accordance with the detailed assessment initiated in this paper, effective communication, proper understanding of the particular medical complications and enhanced collaboration with the patient are indeed essential in order to navigate the “ethical complexities” of the paternalism approach practiced by the physicians.

Reference list

Genuis, Quentin IT. "A Genealogy of Autonomy: Freedom, Paternalism, and the Future of the Doctor–Patient Relationship." The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine. Vol. 46. No. 3. US: Oxford University Press, 2021. https://doi.org/10.1093/jmp/jhab004

Hostiuc, Mihaela, et al. "Physician-Patient Relationship in Current Cosmetic Surgery Demands More than Mere Respect for Patient Autonomy—Is It Time for the Anti-Paternalistic Model?." Medicina 58.9 (2022): 1278. https://doi.org/10.3390/medicina58091278

Murea, Mariana, Carl R. Grey, and Charmaine E. Lok. "Shared decision-making in hemodialysis vascular access practice." Kidney International 100.4 (2021): 799-808. https://doi.org/10.1016/j.kint.2021.05.041

Schwartz, Robert L. "Autonomy, futility, and the limits of medicine." Cambridge quarterly of healthcare ethics 1.2 (1992): 159-164. https://doi.org/10.1017/S0963180100000268

Vogel, Amyn, Felix Balzer, and Daniel Fürstenau. "The social construction of the patient-physician relationship in the clinical encounter: Media frames on shared decision making in Germany." Social Science & Medicine 289 (2021): 114420. https://doi.org/10.1016/j.socscimed.2021.114420