Where respect for autonomy is not the answer.

Abstract

In a series of preceding articles on medical ethics, Gillon emphasized the centrality of the principle of respect for autonomy. Here he outlines several types of circumstances in which medical paternalism is morally justified based on the Hippocratic principles of medical beneficence and non-maleficence. The most obvious examples are circumstances of considerably impaired "autonomy of thought," as in the case of young children or severely mentally handicapped persons. Impairment of "autonomy of action," as in physical handicap, does not justify overriding respect for autonomy. Paternalism may be justified by gross impairment of "volitional autonomy," caused either by intrinsic factors such as severe depression or by extrinsic factors such as duress. There is need for a dialogue between the medical profession and society to decide on criteria for determining competence and for establishing who is to make proxy decisions for incompetent patients.