Monday, 8/3
Paternalism and Autonomy
Readings
Texts
Notes
- Dworkin's Argument
- The Practical Impossibility Argument
- The Irrational Patient and the Placebo Arguments
Cases
Synopsis
Today we took up the thorny issue of professional paternalism. As professionals, that is, you will exercise your particular expertise--in whatever field that may be--on behalf of your clients. On the Priestly (most bossy) Model, you make all the decisions on behalf of your client and simply inform them (or not) what you are doing. On the Mechanic (least bossy) Model, you provide your client with a list of their options together with an informed estimate of likely outcomes and let the client decide entirely on their own what they wish to do.
To be sure, it is tempting, especially for busy professionals such as those we find in medicine or engineering, to veer on the continuum of Mechanic Model to Priestly Model towards the Priestly Model. It's faster, simpler, and easier for the professional to just assume complete control of the situation.
Is there a principled way, however, for the professional to decide when to favor a Priestly approach over the Mechanic approach (or, conversely, when to favor the Mechanic approach over bossier alternatives on the continuum)?
Dworkin presents an interesting philosophical analysis of Paternalism. While he does not draw a sharp distinction between weak and strong paternalism - and perhaps there is no sharp distinction to be drawn - he does argue that Mill was mistaken to reject paternalism. According to Dworkin, the wager view by which Mill justifies paternalism with respect to children can be extended to adults.
But extending the wager view to adults requires that we assume that, if the adult were fully rational, the adult would concur with our restrictions on his or her autonomy. What this implies is that
- Those who would restrict an individual's autonomy bear the burden of proof-i.e., they must demonstrate that paternalism is justified. It is not required that the individual justify that paternalism is wrong, since autonomy is presumptively favored over paternalism in the same sense in which a defendant in a criminal trial enjoys the presumption of innocence.
- In cases were paternalism can be confidently justified, the alternative which least restricts autonomy should be adopted over any other alternative.
Given these restrictions on paternalism, it is astonishing to realize the extent of unjustified paternalism on the part of the Federal and State Governments. For example, the so-called 'War on Drugs' and the prohibition of drugs for recreational use is morally illicit, since the government has clearly failed to adopt the alternatives which least restrict autonomy, even assuming it has borne the burden of proof to justify the prohibition, which, to be sure, it has not.
The issue of paternalism in medicine is most dramatic in cases of truth-telling. As the cases in the first set of notes indicate, truth-telling sometimes poses surprisingly complicated problems for medical professionals. Although the cases we considered come from medical ethics, similar problems can be found in virtually any profession.