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Abstract

Paternalism and especially medical paternalism, the paternalism of physicians and other healthcare professionals toward patients, occupied center stage in the early decades (1970s–1980s) of bioethics, especially in bioethics in the United States. The concepts of paternalism and medical paternalism in bioethics have roots in the general concept of paternalism, the assertion of epistemic and moral authority, and the power such authority justiﬁes, over children by fathers, historically, and parents. Utilizing relevant ethical concepts and principles, the concept of medical paternalism is elucidated, to identify its individually necessary and jointly sufﬁcient conditions: (1) a physician or other healthcare professional undertakes actions designed to limit the exercise of the patient’s autonomy (2) on the basis of clinical judgment and decision-making that are reliably beneﬁcence based about how to protect the health-related interests of the patient from the consequences of the patient’s decisions and actions based on them. The presumption in bioethics, especially bioethics in the United States, that medical paternalism was an accepted ethical norm and therefore common clinical practice in the history of medicine is described and then called into question. This discussion suggests that the importance of medical paternalism for the future of bioethics has become an open question.

Introduction

This entry provides a conceptual and historical account of two key related concepts in the ﬁeld of bioethics, paternalism and medical paternalism. The conceptual account places the concept of paternalism in bioethics in the contexts of paternalism more generally, in the form of asserted epistemic and moral authority and power of parents over their children, and the reﬁnement of the concept of paternalism in canonical bioethics literature during the past four decades. Utilizing the ethical concepts of beneﬁcence and respect for autonomy, the concept of medical paternalism is elucidated, to identify its individually necessary and jointly sufﬁcient conditions: (1) a physician or other healthcare professional undertakes actions designed to limit the exercise of the patient’s autonomy (2) on the basis of clinical judgment and decision-making that are reliably beneﬁcence based about how to protect the health-related interests of the patient from the consequences of the patient’s decisions and actions based on them.

The presumption in bioethics, especially bioethics in the United States, that medical paternalism was an accepted ethical norm and therefore common clinical practice in the history of medicine is called into question. The result is that the importance of medical paternalism for the future of bioethics has become an open question.

History And Development

Parental Authority And Power Over Children

As many scholars in bioethics have noted, the word “paternalism” takes its meaning from the epistemic and moral authority and subsequent power that fathers – and, more generally, parents (hence the use by some of “parentalism”) – have and exercise over their minor children. Paternal epistemic authority is the claim to know better than the child what is in the child’s interest: the stakes that the child is reliably understood to have in his or her immediate, short-term, and long-term future. Such authority is claimed as a matter of paternal responsibility to protect minor children from themselves, especially when they make and then act on decisions that are likely to have serious, far-reaching, and irreversible consequences for the child and adult he or she will become. The authority claimed is epistemic – to understand a child’s immediate, short-term, and long-term interests better than the child does. Such a claim to epistemic authority need not be infallible but should be reliable, i.e., have some evidence base. The strength of the claim to epistemic authority will therefore vary as a function of the evidence for judgments about what is in the child’s interest. There is good reason for parental claims to epistemic authority: younger children and adolescents usually do not have a well-developed sense of and appreciation for their short-term and long-term futures, whereas their parents usually do. Parental moral authority is based on the fundamental moral relationship between any parent and any child: the duty to nurture and protect the child into adulthood.

Parental epistemic and moral authority of parents over their minor children warrants parental power (the ability to make and effect decisions) over their minor child, to make and carry into effect decisions for that child. The power thus exercised may replace either the decision-making of the child with that of the parent or the action of the child with that of the parent or action of the child enforced by the parent. If the assertion of parental authority lacks epistemic authority or moral authority, e.g., if the assertion of power can reliably be predicted to result in net harm to the child and the parent should have known this, then paternalism is not warranted epistemically or ethically. Such paternalism is ethically unjustiﬁed.

The ethical justiﬁcation for the traditional paternalism of parents over their minor child thus has the following components:

The parental claim to epistemic authority should be reliable: the parent must have some evidence base, which can vary in its strength, for his or her judgment about what counts as the child’s immediate, short-term, or long-term interests.
The parental claim to epistemic authority should be transparent: the parent must be able to explain, to himself or herself and to the child, the evidence base for his or her judgment about what counts as the child’s immediate, short-term, or long-term interests.
The parent’s claim to moral authority should be grounded in the fundamental obligation to nurture and protect the child and not in the parent’s self-interest or the interests of others.
The decision of the parent should be reliably understood and designed to secure the immediate, short-term, or long-term interest (s) judged by the parent to be at stake in the child’s decisions.
The action of the parent should be reliably understood and designed to secure the immediate, short-term, or long-term interest (s) judged by the parent to be at stake in the child’s actions.

There is an implicit assumption in this ethical justiﬁcation of paternalism: the child’s decisions and actions do not command the respect of an adult’s decisions and actions. Put another way, by reason of immaturity – especially the relative lack of experience and the insufﬁciently developed ability to conceive of short-term, intermediate, and long-term consequences of one’s decisions and actions – the child does not have the same right to be free to the controlling decisions and actions of another that adults have. By contrast, adults do have rights, especially the negative right to noninterference with their decisions or actions unless those actions pose predictable harm to others, and those others have not consented or should not be presumed to have consented to be exposed to such risk of harm.

The Ethical Concept Of Paternalism In Bioethics: Medical Paternalism

Opposition to physician paternalism, or medical paternalism, has been a deﬁning feature of bioethics from its origins in the United States. There is a vast literature on the topic, reﬂecting the centrality and importance of the topic to the ﬁeld of bioethics. The ethical concept of paternalism has undergone signiﬁcant development in the history of bioethics over the past four decades.

In the ﬁrst edition of the Encyclopedia of Bioethics, “paternalism” is deﬁned as “practices that restrict the liberty of individuals, without their consent, where the justiﬁcation for such actions is either the prevention of some harm they will do to themselves or the production of some beneﬁt for them that they would not otherwise secure” (Beauchamp 1978, p. 1194).

The Principles of Biomedical Ethics, from its ﬁrst edition in 1979 through its latest seventh edition in 2013, has become the most commonly used textbook in college and university courses in bioethics in the United States and in many other English-speaking countries. Beauchamp and Childress deﬁned “paternalism” in the ﬁrst edition of Principles as: “overriding a person’s wishes or actions in order to beneﬁt or prevent harm to that person” (Beauchamp and Childress 1979, p. 155). The seventh edition sets forth a more complex deﬁnition:

…the intentional overriding of one person’s preferences or actions by another person, where the person who overrides justiﬁes this action by appeal to the goal of beneﬁtting or of preventing or mitigating harm to the person whose preferences or actions are overridden. (Beauchamp and Children 2013, p. 215, emphasis original)

Beauchamp, writing for himself, makes the important distinction between the “autonomylimiting” and the “preference-limiting” deﬁnitions of paternalism. They are, respectively, the following:

… the autonomy-limiting deﬁnition: Paternalism is the intentional limitation of the autonomy of one person by another, where the person who limits autonomy justiﬁes the action exclusively by the goal of helping the person whose autonomy is limited. (Beauchamp 2010, p. 104, emphasis original)

… the preference-limiting deﬁnition: Paternalism is the intentional overriding of one person’s known preferences by another person, where the person who overrides justiﬁes the action exclusively by the goal of helping the person whose will or preference is overridden. (Beauchamp 2010, p. 105, emphasis original)

The second deﬁnition does not require that the individual whose preferences are overridden has the capacity to make and execute autonomous decisions; the ﬁrst deﬁnition does. Following Beauchamp, this entry accepts the ﬁrst deﬁnition as the basis for its account of the concept of medical paternalism, below.

Relevant Ethical Concepts

The Ethical Principle Of Beneficence

In general the ethical principle of beneﬁcence obligates an individual to act in such a way as to result in net beneﬁt for others. To be applicable, this general principle must be speciﬁed to different contexts. In the healthcare setting, this speciﬁcation focuses on the health-related interests of patients: the ethical principle of beneﬁcence obligates physicians and other healthcare professionals to provide forms of clinical management that are reliably expected to result in a greater balance of clinical goods over clinical harms for the patient and thus protect and promote the health-related interests of the patient. Such judgments should be based on the best available evidence about the outcomes of the clinical management under consideration. Forms of clinical management supported by the ethical principle of beneﬁcence are medically reasonable.

The Ethical Concept Of Being A Patient

The ethical concept of being a patient was introduced into the history of medical ethics in the eighteenth century by the Scottish physicianethicist, John Gregory (1724–1773). The concept is beneﬁcence based: an individual human being is presented to a physician or other healthcare professional, and there exist forms of clinical management that are reliably expected to result in net clinical beneﬁt for that individual (McCullough 1998). This concept is not autonomy based: an individual human being can become a patient without his or her consent. Thus, infants and minor children can become patients, as can adult patients in clinical emergencies (life-threatening conditions for which there is safe and effective treatment that must be provided immediately, making it impossible to engage the patient in the informed consent process) or adult patients who have lost the capacity to make decisions, either from diseases such as severe dementia, injuries such as brain trauma, or iatrogenic ally from sedation or anesthesia. This is also a concept free of metaphysical requirements, especially the requirement that the individual human being also be a person. The ethical concept of being a patient is both clinical and practical, with comprehensive application in clinical practice, innovation, and research, unlike the metaphysical concept of being a person.

The Philosophical Concept Of Autonomy

An individual is autonomous when he or she is not under the control of others and is sufﬁciently in control of his or her decisions and actions to be considered their origin. One very demanding conception of autonomy is that of Immanuel Kant (1724–1804), who held that to be autonomous required that an individual become the self-legislating lawgiver and therefore not be subject to the law or rule of another (heteronomy), who may be corrupt. An individual achieves such self-mastery by conforming all moral judgments and actions based on them to the categorical imperative to treat others always as ends in themselves (autonomy). For Kant, becoming autonomous is not automatic, e.g., achieving the legal age of adulthood, but the result of sustained, lifelong self-discipline and sacriﬁce required to act always from duty and not from self-interest. David Hume (1711–1776) and John Stuart Mill (1806–1873) put forth a somewhat less demanding conception. To be autonomous requires that an individual not be subject to external controlling inﬂuences. The bioethics literature on paternalism has been dominated by this less demanding conception of autonomy. All adult patients are presumed to have the capacity for autonomous decision-making (decisional autonomy) and action (executive autonomy), putting the burden of proof on the clinician to establish reliably that the patient lacks either decisional or executive autonomy.

The Ethical Principle Of Respect For Autonomy

The ethical principle of respect for autonomy obligates the physician to empower the patient, or the surrogate of a patient who is not able to make decisions for himself or herself by reason of decisional incapacity or minor legal status, to make decisions by providing him or her with information that the patient or surrogate decision-maker needs to exercise his or her autonomy meaningfully in decision-making about proposed clinical management: the nature of the proposed clinical management and why it is medically reasonable, the medically reasonable alternatives, and the clinical beneﬁts and risks of each medically reasonable alternative. The physician should attempt to ascertain that the patient or surrogate decision-maker understands this information and that his or her decision-making process is voluntary.

Ethical Dimension

The Concept Of Medical Paternalism

Paternalism in the clinical setting, or medical paternalism, occurs when (1) a physician or other healthcare professional undertakes actions designed to limit the exercise of the patient’s autonomy (2) on the basis of clinical judgment and decision-making that are reliably beneﬁcence based in order to protect the health-related interests of the patient from the consequences of the patient’s decisions and actions based on them. Each of these two conditions is individually necessary for medical paternalism to be justiﬁably attributed to a physician’s or other healthcare professional’s actions in patient care. Taken together these two conditions are jointly sufﬁcient for medical paternalism to be justiﬁably attributed to a physician’s or other healthcare professional’s actions in patient care.

In the technical language of logic, a necessary condition invokes the argument form of modus tollens (if p, then q; not q; therefore not p) with q as the necessary condition for p: in the absence of q, p does not occur. For the concept of medical paternalism, if either the ﬁrst or the second condition is not the case, then the concept of medical paternalism does not apply to the physician’s or other healthcare professional’s actions. Jointly sufﬁcient conditions invoke modus ponens (if p and q, then r; p and q; therefore r). For medical paternalism, if both the ﬁrst and second conditions are the case, then the concept of medical paternalism does apply to the physician’s or other healthcare professional’s actions. The minor premise, “p and q,” is a conjunction, which is true if and only if both conjuncts are true. This is the logical meaning of “jointly sufﬁcient.” Both conditions must be satisﬁed for the action of a physician or other healthcare professional to be categorized as medical paternalism.

Medical Paternalism: A Core Topic In Bioethics

As a beneﬁcence-based ethical concept, the concept of being a patient includes an intrinsic potential for paternalism. This is because the second of the two individually necessary and jointly sufﬁcient conditions for the clinical application of the concept of medical paternalism explicitly invokes beneﬁcence-based clinical judgments about how to protect and promote the health-related interests of patients and the professional responsibility to protect and promote those interests in patient care. This includes the responsibility to protect the patient from himself or herself, e.g., by advising against behaviors such as smoking or excessive consumption of spirit beverages that are known to put health and life at risk. Inasmuch as such clinical judgments are both evidence-based and beneﬁcence-based in their evaluation of the evidence, they are expert clinical judgments. Thus, this second condition reﬂects the claim of parents to epistemic and moral authority over minor children. The epistemic authority of physicians and other healthcare professionals over patients is a function of the reliability of their evidence-based clinical judgments. The moral authority of physicians and other healthcare professions over patients is a function of the reliability of their evidence-based evaluation of the processes and outcomes of clinical management to determine whether the outcome is of net clinical beneﬁt for the patient and therefore medically reasonable and the professional commitment to implement medically reasonable alternatives to protect the health and life of the patient.

The early literature of bioethics in the 1970s in the United States repeatedly identiﬁed medical paternalism as a major ethical issue of widespread occurrence in clinical practice and as an accepted ethical norm and practice in the history of medicine. The Encyclopedia of Bioethics entry, referenced above, characterized “issues of paternalism in bioethics” as follows: “There are so many individual examples of controversial paternalistic justiﬁcations in biomedical and behavioral contexts that only a few selected samples can be treated here” (Beauchamp 1978, p. 1197). This entry conveyed the accepted view at the time: physicians regularly engaged in paternalism in the patient care, without sufﬁcient justiﬁcation, and had done so throughout the history of Western medicine. The view that medical paternalism is a major ethical concern is not conﬁned to the early period of bioethics. This view can also be found in the literature of the ﬁeld in its mature period: “… paternalism may be the most pervasive moral problem in medicine.. .” (Gert et al. 1997, p. 195).

Bioethicists often traced the roots of medical paternalism as a medical ethical norm and therefore accepted clinical practice back to the Hippocratic Oath and texts and what has been called the Hippocratic Tradition in medical ethics, i.e., a tradition of medical paternalism persisting from ancient Greece down to the present. Veatch castigated the Hippocratic Oath for its “paternalistic Hippocratic patient-beneﬁtting principle” (Veatch 1976, p. 248). The Hippocratic Tradition supported not being truthful with patients and thus violated the patient’s “right and duty to consent to their medical treatment based upon reasonable knowledge of their medical conditions” (Veatch 1976, p. 241).

Katz’s Silent World of Doctor and Patient communicated in its very title the centrality of medical paternalism as a moral problem in clinical practice. Referencing works from the history of Western medical ethics, Katz argued that the paternalism of not being forthcoming with patients about their illnesses and the management of them was an accepted ethical standard by physicians and put into clinical practice:

The history of the physician-patient relationship from ancient times to the present bears testimony to physicians’ caring dedication to their patients’ physical welfare. The same history, by its account of the silence that has pervaded this relationship, also bears testimony to physicians’ inattention to their patients’ right and need to make their own decisions. Little appreciation of disclosure and consent can be discerned in this history, except negatively, in the emphasis on patients’ incapacities to apprehend the mysteries of medicine and, therefore, to share the burdens of decision with their doctors. (Katz 1984, p. 28)

The principal form of medical paternalism was withholding information from patients that they have the right to know. Patients have the positive right to be provided information that they need in order to make informed decisions in the exercise of their autonomy. Patients have the negative right not be to controlled by others in their decision-making processes. The physician’s obligations to provide such information and not to interfere with the patient’s decision-making processes were understood in this literature to be required by the ethical principle of respect for autonomy.

Medical paternalism in the form of withholding information from patients limits a patient’s autonomy by restricting the range of options for the patient to learn about, evaluate, and consider authorizing. This account invokes a concept of decisional autonomy that holds that a decision cannot be autonomous if the decision-maker was not aware of all of the options available to him or her in a particular decision-making context. This form of limiting autonomy is especially insidious in contexts in which expert knowledge and experience are required to identify the options that are open to the decision-maker. Medical care is one such context. The typical patient, considered as a layperson of average sophistication about health and healthcare provided by healthcare professionals, cannot reasonably be presumed to be aware of all of the medically reasonable alternatives for the clinical management of his or her condition, disease, disability, or injury. The typical patient will therefore be unaware that a physician or other healthcare professional has withheld information about medically reasonable alternatives. When information about medically reasonable alternatives is withheld from the patient without the patient’s knowledge and when this is done for beneﬁcence-based reasons, i.e., to protect the health (including general well-being) or life of the patient, then the action of such withholding of information satisﬁes the jointly sufﬁcient conditions for the application of the concept of medical paternalism.

Another form of medical paternalism, of which the typical patient is usually aware, is interfering with the patient’s autonomy of action forcing treatment on a patient for his or her own good when the patient has, as a result of the informed consent process, exercised his or her autonomy to refuse such treatment. In such cases, the limitation on autonomy takes the form of selecting for the patient the medically reasonable alternative for the patient and then implementing it despite the patient’s express refusal. The patient’s decision and action are both overridden. When such overriding of patient autonomy is justiﬁed by an appeal to the healthcare professional’s beneﬁcence-based obligation to protect the health and, especially, the life of the patient, the jointly sufﬁcient conditions for the application of the concept of medical paternalism have been satisﬁed.

A paper by Oken (1961) was – and still is – cited in the American bioethics literature as providing evidence for the clinical acceptability and practice of medical paternalism. In a qualitative, descriptive study of a convenience sample of physicians in one hospital in the City of Chicago, Illinois, Oken documented that 88 % of his respondents reported that they withheld the truth about patients’ bad conditions and prognoses from them. A closer look at Oken’s data reveals that only 8 % never were honest with their seriously ill patients. One of the main reasons that this group of physicians expressed to justify not being honest with seriously ill patients was the emotional burden on the physician. These physicians were limiting patient autonomy by not providing patients with the diagnostic and prognostic information that they required for making informed decisions about the clinical management of their conditions. The ﬁrst necessary condition for the application of medical paternalism was satisﬁed. The second necessary condition, however, was not: physicians were withholding information, not for the beneﬁt of the patient (the second necessary condition of medical paternalism) but mainly for their own beneﬁt and their self-interest in protecting themselves from the impact on them of giving bad news to patients.

The concept of medical paternalism therefore does not apply, yet it was invoked by bioethicists who cited the Oken article. This suggests that the core objection to medical paternalism for many American bioethicists is that the ﬁrst necessary condition, limiting the autonomy of the patient, is also by itself the single sufﬁcient condition for the application of the concept rather than one of two jointly sufﬁcient conditions. That such a position results in conceptual confusion has not been recognized by these bioethicists (McCullough 2011). Not giving patients bad news because doing so is emotionally burdensome for the physician is surely a limitation of the patient’s autonomy of decision-making and therefore of action, but this practice is not accurately characterized by “medical paternalism” because the second of two individually necessary and jointly sufﬁcient conditions for the application of this concept is not satisﬁed. That a physician’s or other healthcare professional limits patient autonomy is not eo ipso medical paternalism, unless medical paternalism is equated to limiting patient autonomy.

American bioethicists were also mistaken that not being honest with seriously ill patients was an accepted ethical norm and practice. For example, the two giants of British Enlightenment medical ethics, who invented modern professional medical ethics (McCullough 1998, 2006), did not embrace such a norm. John Gregory (1724–1773), the Scottish physician-ethicist, took just the opposite view and argued for the obligation to be honest as an “indispensable” duty of physicians (McCullough 1998, 2011). Thomas Percival (1740–1804), the English physician-ethicist, held that being honest with seriously ill patients was among the “ofﬁces” or duties of a physician (McCullough 2011).

Being honest with patients and providing them with information that they needed to participate in decision-making about their clinical care became clinical practice as early as the nineteenth century in the United States. Powderly (2000) has beautifully documented the consent practices of a gynecologist in the City (now Borough) of Brooklyn, Alexander Skene (1837–1900). He routinely provided his patients with information about their diagnoses, both medical and surgical means of clinical management, engaged his patients in the decision-making about the clinical alternatives, and negotiated care plans when patients refused his recommendations. All of Dr. Skene’s patients were women. If there were a patient population at risk for being subject to medical paternalism by male physicians (and almost all physicians in the United States at that time were men), it would be female patients. Dr. Skene’s anti-paternalistic clinical practice is therefore all the more remarkable counterexample to the supposed “Hippocratic Tradition” of medical paternalism in Western medicine (McCullough 2011). Recent scholarship (Nie 2009) suggests that paternalism in communicating with patients was not accepted as a norm or practice in the history of Chinese medical ethics.

The self-understanding of bioethics in the United States in its early decades was that it provided an ethically urgent corrective to the rampant, accepted medical paternalism of physicians. This self-understanding is reﬂected, for example, in the entry on paternalism in the ﬁrst edition of the Encyclopedia of Bioethics (Beauchamp 1978), a key passage from which about widespread medical paternalism is quoted above. McCullough (2011) has recently argued, on the basis of a thorough examination of sources such as Oken and the major texts from the history of Western medical ethics, that the creation of the ﬁeld of bioethics, at least in the United States, was predicated on both historical and conceptual mistakes about medical paternalism. It was not accepted as an ethical norm by major physician-ethicists in the history of medical ethics, and it was not a widely accepted practice.

Conclusion

The concepts of paternalism and medical paternalism have played a central role in the ﬁeld of bioethics, especially during its formative years in the United States. Recent scholarship in the history of medical ethics suggests that this central role for these two concepts may not have been justiﬁed. The role that the concepts of paternalism and medical paternalism should therefore play in the future development of the ﬁeld of bioethics has become an open question.

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