Wednesday 11/07

Paternalism and Autonomy

Readings

Texts

• Gerald Dworkin, "Paternalism"
• Mack Lipkin, "On Telling Patients the Truth"

Notes

• Dworkin's Argument
• The Practical Impossibility Argument
• The Irrational Patient and the Placebo Arguments

Cases

• Truth-Telling Cases
• Medical Paternalism Cases
• Cases for Multi-Modal Analysis

Synopsis

As we have seen, the application of Utilitarian Ethical Theory, Kantian Ethical Theory, and Social Contract Theory to particular cases varies remarkably in strategy and, sometimes, outcome. It is important in this regard to repeat that what a theory of morality says about morality shapes how we apply the theory, but it is never the case that a theory should be thought of as, say, a mechanism or black-box that churns out answers to moral problems by turning a crank.

Rather, moral normative theories provide analytical frameworks for circumscribing morally relevant features of particular cases. That is, they give us a scheme to help us think about and better understand the moral dimensions of a troubling case. They sometimes differ in what they say, but they also sometimes agree. The problem is what to do when there is a clear difference between these theories. For then we seem to be forced to make a choice between them, yet it is unclear which theory will ultimately prove true.

Fortunately there are large areas of agreement between Utilitarian Ethical Theory, Social Contract Theory, and Kantian Ethical Theory. In particular, we may consider some of the moral principles which seem equally justifiable on Utilitarian Ethical Theory, Kantian Ethical Theory, and Social Contract Theory grounds: Nonmaleficence, Beneficence, and Autonomy and its four exceptions (Harm, Weak Paternalism, Strong Paternalism, and Welfare). To be sure, this is a lot of material to keep straight.

Today we revisited paternalism, inasmuch as it seems to be involved in a number of our cases. It is also personally of great interest to you. 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 (Gerald Dworkin, "Paternalism") presents an interesting philosophical analysis of Paternalism to which I alluded earlier. 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

1. 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 paternalism is presumptively wrong.
2. In cases were paternalism can be adequately 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 borne the burden of proof to justify the prohibition, which, to be sure, it has not.