Medical Paternalism Research Articles

Decisions Relating to Cardiopulmonary Resuscitation: commentary 1: CPR and the cost of autonomy

Since the last generation medical ethics has seen a remarkable shift from benign medical paternalism to patient rights and autonomy. Whereas once it might have been acceptable for doctors to...

Medical paternalism and the fetus

A number of developments in the medical field have changed the debate about the ethics of abortion. These developments include: advances in fetal physiology, the increase in neonatal intensive care...

Keep taking the PILS

In the olden days, medical paternalism was the norm; it was benevolent, kind, and expedient. Doctors did not have painfully honest conversations with their patients. Instead they dished out euphemisms or gave the sketchiest of explanations. A patient with an abdominal mass might therefore learn that the cells were a bit more active than average, or that there was new tissue forming near the liver. Someone referred for radiotherapy would be told: “The air's not going in and out of your lung as freely as it might, so we'll shine some rays to help things.”

Neurology, technology, and the diagnostic imperative.

Advancements in diagnostic technologies have revolutionized the field of neurology. The use of these tools in the course of neurological evaluations is driven by a strong version of the diagnostic imperative, with the goal of precisely identifying the locus and extent of disease processes. Because of the discrepancy between the sophistication of these technologies and the availability of therapeutic interventions, there is active debate regarding the appropriate use of these tools when the diagnosis is clear, or when no change is made to the therapeutic management. A narrow view of management that is bounded by the availability of pharmacological or surgical interventions results in a more rigid dichotomy between the needs of doctors and patients. A broader view that relaxes the constraint between diagnostic procedures and interventions is more in keeping with the observation that many acts are performed for the benefit of doctors and patients alike. An historical and ethical analysis of the diagnostic imperative, with attention to the rise of innovative medical technologies and current concepts of therapeutic intervention, can help clarify the principles of medical paternalism and beneficence that guide current models of decision making in the neurological sciences.

Patient decision making competence: outlines of a conceptual analysis.

In order to protect patients against medical paternalism, patients have been granted the right to respect of their autonomy. This right is operationalized first and foremost through the phenomenon of informed consent. If the patient withholds consent, medical treatment, including life-saving treatment, may not be provided. However, there is one proviso: The patient must be competent to realize his autonomy and reach a decision about his own care that reflects that autonomy. Since one of the most important patient rights hinges on the patient's competence, it is crucially important that patient decision making incompetence is clearly defined and can be diagnosed with the greatest possible degree of sensitivity and, even more important, specificity. Unfortunately, the reality is quite different. There is little consensus in the scientific literature and even less among clinicians and in the law as to what competence exactly means, let alone how it can be diagnosed reliably. And yet, patients are deemed incompetent on a daily basis, losing the right to respect of their autonomy. In this article, we set out to fill that hiatus by beginning at the very beginning, the literal meaning of the term competence. We suggest a generic definition of competence and derive four necessary conditions of competence. We then transpose this definition to the health care context and discuss patient decision making competence.

末期病人的決策倫理: 三個模式的比較

LANGUAGE NOTE | Document text in Chinese; abstract also in English.本文討論末期病人的決策過程的三個模式，即個人主義、家長主義和家庭本位主義。個人主義過份偏重病人的抉擇，家長主義只強調從專業角度照顧病人的個人最佳利益，這兩個模式均會令家庭角色邊緣化。本丈認為家庭本位主義，更符合東方社會文化，從倫理角度來看亦較其他兩個模式可取。This paper critically examines the liberal, the medical paternalist, and the familial models of decision making for the terminally ill. It is argued that the liberal model is excessively patient centered while the medical paternalist model overemphasizes the role of the physician. The paper concludes that since both models marginalize the role of the family in the decision-making process, they are morally inadequate and not suitable for societies with strong family ethics, particularly those in Asia.The liberal model is predominant in the United States. According to this model, a competent patient can express in an advance directive her prior wish of how she is to be treated when she lapses into incompetency. In the absence of an advance directive or in cases where the directive is vague or ambiguous, the surrogate decision-making process will be invoked, which is normally a procedure in which the family makes the decision on the patient's behalf. In this process, the family serves to assist the incompetent patient to exercise her self-determination by figuring out and then following her counterfactual choice in accordance with the substituted judgment standard. If it is impossible to arrive at a decision by following this standard, the family, with the assistance of the physician, will follow the standard of best interests to promote the well-being of the patient. In sum, in the process of surrogate decision making, only the individual choice and interests of the patient are a matter of concern. Thus, the liberal model is entirely patient-centered. The role of the family is marginalized in the sense of being subordinated to the (previous or counterfactual) choice and interests of the patient. The family therefore becomes a "shadow" of the patient with no independent status and is deprived of its self-sufficiency.In the United Kingdom, medical paternalism is more influential. There is a preference for a code of practice to legislation for advance directives, and the prevalence of the best interest standard. Yet, unlike the liberal model, the best interests of the patient are not determined by the family in accordance with the standard of a reasonable person. Rather the doctor is expected to make decision for the patient in accordance with a responsible and competent body of relevant professional opinion in determining the patient's best interests. Though the family will often be consulted, the principal decision maker is the physician. So the role of the family is also marginal in this model.In Asian societies, e.g., Japan, Mainland China and Hong Kong, the family plays a fundamental role in the decision making for the terminally ill, so the model of familialism prevails. In these societies, it is common that the patient will not be informed directly of her terminal illness by the physician. The decision for the incompetent patient is regarded not as an individual but a family decision, and the dying process is viewed a sharing process, the last journey that the patient undergoes together with her significant others.In the familial model, the decision for a terminally ill patient is regarded not entirely as an individual matter because other members will be affected by the patient's choice. Should a son merely consider the wishes or the best interests of his father without considering the burden of care and the feelings of his mother while his father is going through the last stage of his life? Should the mother also consider the financial burden that her son might have to bear for his father if he were to be kept alive at all costs? Such issues would not have a place in the liberal and the medical paternalist models, for what matters is only the choice or the best interests of the patient. On the contrary, due considerations are given to these issues in the familial model, which makes it more plausible than the other two models.DOWNLOAD HISTORY | This article has been downloaded 15 times in Digital Commons before migrating into this platform.

Expanding the kidney donor pool: Ethical and medical considerations

year later, proteinuria developed. She had an uncomplicated pregnancy in 1990. Five years later, arterial hypertension required treatment with enalapril. Her serum creatinine then was 1.2 mg/dL. The serum creatinine rose to 1.3 mg/dL two years ago and to 1.5 mg/dL last year. Earlier this year, a 24-hour urine collection contained 810 mg protein; the serum creatinine was 1.6 mg/dL and the creatinine clearance was 31 mL/min/ 1.73 m 2 . Her urine sediment was benign. A further increase in her blood pressure necessitated treatment with lisinopril, 10 mg each morning, and amlodipine, 5 mg each night. She says that she has no regrets about her decision to donate despite the outcome. Five years ago, her husband’s brother developed renal failure; with her encouragement, her husband donated a kidney. Her husband, now age 44, is in good health and has normal blood pressure, normal serum creatinine, and no proteinuria.

Ethical considerations in composite tissue allotransplantation.

Ethical issues posed by the hand transplant program conducted by hand and plastic surgeons at Jewish and University Hospitals, Louisville, Kentucky, are examined in this essay. Because a composite tissue allotransplantation (CTA) is an experimental procedure, it raises issues as to the protection of human subjects. The background for the emergence of medical ethics as a discipline is indicated and the processes employed by the CTA team in order to address ethical concerns are discussed. Questions are posed as to the justifications for certain procedures and those pertaining to the goals of medicine, informed consent, and patient quality of life. Other issues include benefits versus risks, patient autonomy and medical paternalism or non-maleficence. The Louisville team seems to have dealt conscientiously with all ethical questions that have been posed and has treated the hand recipient with competence and continuity of care. No reasons based in ethical concerns have surfaced that would in any way discredit the program.

The doctor-patient relationship: a survey of attitudes and practices of doctors in Singapore.

This article reports the results of a survey, by mailed questionnaire, of the attitudes, values and practices of doctors in Singapore with respect to the doctor-patient relationship. Questionnaires were sent to a random sample of 475 doctors (261 general practitioners and 214 medical specialists), out of which 249 (52.4%) valid responses were completed and returned. The survey is the first of its kind in Singapore. Questions were framed around issues of medical paternalism, consent and patient autonomy. As the doctors were exposed to Western ethical concepts in their training, we were not surprised to find that they would mostly allow patients some say in decision-making and keep patients reasonably informed. In respecting patient autonomy, they would usually seek to influence patient choice by persuasion. However, the residual 'Asian-ness' of doctors in Singapore gives rise to some inconsistencies between values and practices. Many doctors still believe that a number of their patients are incapable of rational choice. There is some lack of openness in telling patients the whole truth. When patients choose to refuse treatment, many doctors are prepared to involve family members in making a consensus decision. Doctors were also asked how they made ethical judgements in the face of dilemmas, and how they would like disputes with patients to be resolved. By and large, the doctors prefer to make their own judgements rather than to rely on rules. They also wish to keep the law courts out of disputes with patients, preferring less public ways of settling disputes.

關於放棄臨床無效治療的倫理學思考

LANGUAGE NOTE | Document text in Chinese; abstract also in English.對於沒有臨床救治希望的病人，要不要繼續治療？誰有最終的決定權？這既是臨床醫療問題，又是一個涉及社會倫理法規的問題。對於這樣的病人，不放棄治療可能意味著要消耗更多的醫療資源但又無法挽救病人，但是如果放棄治療，可能會遇到更多的來自社會傳統的、倫理法規的問題。筆者認為，在社會多元化發展的今天，面對臨床無效治療，應在尊重病人或病人家屬有最終決定權的前提下，以一定道德、法規為依據，按照一定的醫療程式和法律手續進行處理，可能是更為符合人道和社會公眾利益的理性選擇。There has not been a clear medical definition of futility. The concept of futile treatment involves not only medical, but also social, ethical, and legal components. This paper argues that in today's pluralistic moral circumstances, the patient and/or the family should have the final right to decision regarding futile treatment.Some are opposed to renouncing futile treatment, whatever futility is defined. For them, first, abandoning treatment is in conflict with the physician's basic duty of offering treatment. Second, giving up treatment also gives up the chance of making medical progress by attempting to treat the patient. Third, the patient would thereby lose the opportunity of prolonging the life. And finally, it would change the good image of the physician (as taking care of the patient). On the other hand, those who support renouncing futile treatment offer different reasons. First, giving up futile treatment will turn out to be respecting the value of the patient's life. Second, It would help people recognize the natural limit of contemporary medical development. Third, it would facilitate a reasonable pattern of distributing scarce medical resources. And finally, it could reduce the suffering of the patient. As a result, we face a social situation of moral pluralism: people disagree with each other regarding renouncing futile treatment.A difficult practical issue is who has the right to decide renouncing futile treatment. This paper argues that, giving individuals hold conflicting views of life, valoue and morality, the patient should have the final decision power regarding his/her own treatment. If the patient is incompetent, then the family should have the deciding right. In this respect we should overcome the longstanding medical paternalism. In addition, society should establish a prcocedure to regulate and facilitate the decision-mading of renouncing futile treatment.DOWNLOAD HISTORY | This article has been downloaded 16 times in Digital Commons before migrating into this platform.

Ethical issues of stereotyping.

Stereotyping, particularly negative stereotyping, is an important and pragmatic social issue. Contemporary mores have rightly condemned stereotyping by race, nationality and gender. Stereotyping in medicine has a number of important practical connotations. One of the most important is the attitudinal tradition of medical paternalism. Doctors have often stereotyped patients as subjects not being capable of considering relevant options in their own personal, clinical circumstances - for example, where major surgical intervention might be one course of action. Withholding full information of all the outcomes, and rushing the doctor-patient decision process in such circumstances, constitutes one type of unethical stereotyping.

An end to medical paternalism?

The role of medicine in modern society is expanding and evolving at a rapid pace. Based on the attenuation and application of knowledge, it has been profoundly influenced by the impact of advances in information technology. The continued and massive changes to primary care in this country being one obvious example of this. The sustained growth of the internet has catalysed the development of NHSnet — a secure intranet linking GP's surgeries to secondary care. And the technology's attendant philosophy of empowered consumerism has facilitated the A introduction of J intelligent triage 1 systems like NHS I Direct and the new approach to personal health sym-bolised by Walk In centres.

Criteria for involuntary hospitalisation.

The aim of this paper is to provide an overview of the ethical bases of compulsory commitment legislation. The ethical principles of beneficence and autonomy are examined and used to identify criteria for the commitment of mentally ill patients. Two aspects of beneficence, medical paternalism and social paternalism, are discussed. It is argued that social paternalism is insufficient ethically to warrant involuntary admission, and that the basis for compulsory hospitalisation is medical paternalism. The central role of autonomy in medical ethics suggests a patient should have a diminished capacity for autonomous decision-making and a potential to benefit from hospitalisation, as well as a risk of harm to self (including self-neglect) to warrant committal. In specific circumstances, the risk of harm to others may also justify committal. These ethical principles may be at odds with public attitudes.

Why physician gender matters in shaping the physician-patient relationship.

Societal values regarding the nature and consequences of patient autonomy and medical paternalism underscore the current debates surrounding informed consent and shared decision making. The debate is significant in that it both reflects and determines normative expectations for physician and patient conduct as well as the nature and form of the therapeutic relationship. Analysis of the literature describing communication differences between physicians of different genders indicates that female physicians show a greater affinity for collaborative models of patient-physician relationship than do their male colleagues. Female physicians spend more time with their patients, are more likely to engage their patients in discussions of their social and psychologic context, and deal more often with feelings and emotions. Moreover, female physicians facilitate partnership and patient participation in the medical exchange more effectively than do male physicians. The authors propose that the quality of the interactive process is critical to the establishment of a therapeutic relationship and that this process is related to physician gender. They also suggest that physician gender matters in the shaping of the patient-physician relationship through this interactive process.

Ethical decision-making in newborn infants.

One ethical dilemma which neonatologists are faced with on a regular basis is selective non-treatment, that is, clinical decisions made after the birth of a liveborn infant to withhold or to withdraw treatment in certain circumstances. Although the outcome of extremely preterm of critically ill infants has significantly improved over the last decade, many are often left to die at birth by withholding resuscitation or neonatal intensive care. Criteria for initiating life-sustaining treatment must be developed with proper ethical considerations. There are other infants whose clinical course after initiation of intensive care will suggest that further curative efforts are futile or lack compensating benefit. Criteria for withdrawing life-sustaining treatment must also be developed, and palliative care measures defined. Clinical situations in which selective non-treatment is taking place in neonatal medicine are: (1) when death is considered to be inevitable whatever treatment is provided, (2) even when death is not inevitable, there is a significantly high risk of severe physical and mental disability should the infant survive, and (3) when survival with moderate disability is possible, but the infant is likely to experience ongoing pain and suffering, repeated hospitalisation and invasive treatment, and early death in childhood. The decision-making process of selective non-treatment should involve less medical paternalism and more informed parental involvement. The process is built on trust between the neonatal staff and parents, and requires time, information, honesty and empathy. Ethical issues must be approached with extreme responsibility, extraordinary sensitivity and heroic compassion.

Good enough risk taking

People with some psychiatric disorders, as with many other disorders of health, are more likely to pose risks of harm to self or others than healthy people. Effective management and treatment necessarily involves a certain amount of risk taking in this regard. Psychiatrists and their allied professional colleagues, trapped somewhere between medical paternalism and inquiry culture and the civil rights complaints milieu are more inclined than not to share a conservative view of risk taking as the moral equivalent of gambling. The law at present compounds this with its binary, all or nothing, approach to risk assessment, whether in courts or review bodies. More imaginative, yet practical and testable approaches which reflect the dynamic process of risk development and reduction are considered. They are recommended for law and psychiatry, and in particular for the interface between them.

An Ethical Dilemma: Commentary: Disciplinary processes should not be used to solve ethical problems

The report suggests that managerially, it was apparently “wrong” for the nurse to deceive the patient (which justified the final warning) but not “wrong” for the doctor to have ordered the deception. This suggests that the ethical duties of doctors and nurses are perceived as different. However, it seems hard to argue that nurses should be more honest than doctors in their clinical practice unless it is important to protect a tradition of strong medical paternalism. The author also raises concerns about a style of nursing management. Some of these concerns are not peculiar to nursing: the …

The police surgeon's view Medical paternalism is unacceptable

Police surgeons (otherwise known as forensic medical examiners in metropolitan London and forensic medical officers in Northern Ireland) are mostly general practitioners, and they may see both the victims and the perpetrators of violent and sexual assaults. They may be asked to attend accident and emergency departments and sometimes paediatric wards in order to assist with the documentation of injuries, the compilation of police statements, and to conduct joint examinations with paediatricians in cases of alleged physical and sexual child abuse. Police surgeons may also see those accused of such assaults, who may themselves be injured, with a view to establishing their …

Managed Care and the New Medical Paternalism

Previous articleNext article No AccessManaged Care and the New Medical PaternalismDaniel P. SulmasyDaniel P. SulmasyGeorgetown University Medical Center, Washington, D.C. Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by Volume 6, Number 4Winter 1995 Published on behalf of the MacLean Center for Clinical Medical Ethics Article DOIhttps://doi.org/10.1086/JCE199506406 © 1995 The University of Chicago. All rights reserved.PDF download Crossref reports no articles citing this article.

The physician's authority to withhold futile treatment.

The debate over futility is driven, in part, by physicians' desire to recover some measure of decision-making authority from their patients. The standard approach begins by noting that certain interventions are futile for certain patients and then asserts that doctors have no obligation to provide futile treatment. The concept of futility is a complex one, and many commentators find it useful to distinguish 'physiological futility' from 'qualitative futility'. The assertion that physicians can decide to withhold physiologically futile treatment generates little controversy. The claim that they can withhold qualitatively futile treatment runs afoul of standard objections to medical paternalism. There is reason to believe that the conceptual distinction will not be maintained in clinical practice. This paper contends that the scientific data which would support a physician's unilateral decision to withhold physiologically futile treatment also provide support for an institutional policy restricting access to the treatment. The data the doctor uses to take decision-making power out of the hands of the patient can be used by the administrator to take power out of the hands of the doctor. While this loss of power is unproblematic, there is reason to believe that the ambiguity in the term 'futility' will allow a much greater loss of physicians' power.