Psychiatric paternalism between Scylla and Charybdis

Abstract

As much as strong medical paternalism should never be exercised, some weak paternalism towards patients is, on the contrary, part of physicians' and society's moral obligation. So far, this is a widely consented position in medical ethics. What then are the defining and the justifying conditions for legitimate weak paternalism in psychiatry? In this presentation it is argued in favor of three necessary and jointly sufficient conditions for ethically acceptable/obligatory paternalism: (1) the patient must lack specific competency to evaluate his or her treatment options in a sufficiently autonomous way; (2) there must not be evidence that the patient had, in a former healthy state, been opposed to weak paternalism; (3) there must exist treatment options with a truly acceptable cost-benefit balance, that cannot be postponed until regain of competency, without harming the patient. Even if this seems a plausible normative frame, there remain difficulties in detail for both conceptual ethical theory and psychiatric practice. Among them are: assessing patient competency, avoiding undue control in patient preference formation, identifying third parties' interests, and evaluating treatment options. For psychiatry's self-understanding, societal image, and acceptance by patients and their families, it seems important to tackle these issues so as to get a coherent and transparent picture of the justification and limits of psychiatric paternalism.