Medical paternalism

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Medical paternalism is a set of attitudes and practices in medicine in which a physician determines that a patient's wishes or choices should not be honored. These practices were current through the early to mid 20th century, and were characterised by a paternalistic attitude, surrogate decision-making and a lack of respect for patient autonomy. [1] It is almost exclusively undertaken with the intention of benefiting the patient, although this is not always the case. In the past, paternalism was considered an absolute medical necessity, as there was little to no public understanding of medical procedures and practices. However, in recent years, paternalism has become limited and blind faith in doctors' decisions has come to be frowned upon. [2]

Contents

By the end of the 20th century and into the 21st, paternalistic medicine was increasingly seen as inappropriate in the West with guidance from professional bodies such as the General Medical Council indicating that it is ethically unsupportable. [3]

History

Historical view

Traditionally, patients' roles were similar to that of a helpless, passive infant, while doctors held a dominant, parental position. [4] In Medieval Europe, doctors held highly esteemed, almost magical positions, while patients were seen as helpless. In the 18th and 19th centuries, it was believed that only a doctor could properly understand symptoms and draw useful conclusions. During this period, the prevailing consensus was that disease was nothing more than symptoms. [4] This meant that the individual history of the patient did not matter in providing care, so the patient him or herself was irrelevant in the medical encounter. Thus it was deemed necessary that physicians make decisions for patients; information given to patients was often limited to what the physician perceived as not causing harm. [5]

Historical examples

In 1847, the American Medical Association's Code of Ethics stated:

The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them. A failure in one particular may render an otherwise judicious treatment dangerous, and even fatal.

— American Medical Association, Article II, "Obligation of patients to their physicians", Code of Medical Ethics [6]

This view of paternalism was only encouraged by the rise of hospitals in the later 18th century. Because patients in hospitals were often sick and disabled, the view of them as passive recipients of medical care only became more prevalent. [4]

An 1888 physician's manual "encouraged physicians to withhold information to prevent patients from becoming medically self-sufficient." [5] Physicians were encouraged to obfuscate test methods, medication names, and treatments, as well as withhold the abusive and addictive potential of medicines used at the time. [7]

In the 1950s, an article in the Journal of the American Medical Association covered whether or not a cancer patient (and/or their family) should be informed of the condition, in an attempt to limit potential distress. The patient or family may be instead have been told of an infection or bowel blockage requiring surgery. If the patient was informed and experienced severe distress – "if they return to a pseudoinfantile state" – "they should be handled in many respects as children", potentially requiring a prefrontal lobotomy. [8] As late as 1961, the vast majority of American doctors (90%) did not inform patients about cancer diagnoses. [5]

Movement away from paternalism

The movement away from paternalism can be traced back to the relationship between early psychologists and their patients. In particular, Josef Breuer and Sigmund Freud urged that importance be placed on communication with and understanding of the patient. [4] This sharply contrasted the view of patients as passive, and placed them at the center of the medical encounter. These practices also treated patients as unique, instead of simply being a collection of symptoms to be fixed by a paternalistic doctor.

In 1956, Szasz and Hollender [9] introduced three models of paternalism to the medical community, thereby legitimising the view that doctors did not necessarily have to dominate patients. The models are as follows:

In the latter 20th century, in part due to a focus on patients' rights, greater emphasis on communication in healthcare, and improved medical treatments, the partnership model and patient autonomy have become more common, particularly in Western countries. [10]

Strong vs. weak paternalism

Strong and weak paternalism (sometimes referred to as limited and extended paternalism) are two philosophies regarding when it is appropriate for a doctor to ignore a patient's wishes. The fundamental difference lies in the patient's capacity to make well-informed decisions for themselves. [11] [ page needed ] Weak (or limited) paternalism refers to a situation in which the physician will only disobey the patient's requests if the patient cannot demonstrate that their choices are voluntary and well-informed. As such, even if the doctor disagrees with the patient's desire, he or she will not intervene as long as the patient is of sound mind. Strong (or extended) paternalism involves a doctor superseding a patient's requests in cases where the doctor has determined a better course of action, even when the patient's requests are made voluntarily. These cases typically arise when the physician has determined that a patient's decision is unreasonable because of the risks involved, or potential costs to the patient's well-being. [12] [ page needed ]

Legality

Due to the subjective nature of when and to what extent paternalism is necessary, physicians who engage in paternalism may find themselves in a complicated legal situation. Throughout history there have been many cases in which a patient is reported to have made a well-informed choice (while of sound mind) to opt for a medically improper treatment, or one that is very costly to their well-being. If the doctor does not take a paternalistic stance, and instead goes through with the patient's wishes, the question arises as to whether malpractice occurred. [13] There exists an expectation of doctors to provide as much information as is appropriate to their patients, as well as an expectation that they do not keep anything relevant secret. This creates a difficult legal situation in which a decision has to be made about what the correct amount of information is, and how best to present it. For example, a patient may read everything available to them and ultimately decide on undergoing a procedure with a 95% survival rate. However, that same patient may not choose the same procedure if it is presented as carrying a 5% risk of dying. As such, in cases in which things go awry it is the courts' responsibility to determine whether the physician is at fault, and whether he or she should have ignored the patient's requests. [14]

Relationship with euthanasia

In many cases, particularly countries in which voluntary euthanasia is illegal, physicians must exercise medical paternalism by not respecting patients' wishes to die. There are contrasting views on whether this constitutes weak or strong paternalism. One argument is that weak paternalism allows the physician to stay completely hands-off. If the patient is in a sound state of mind and the doctor can reasonably guess what they desire, so there is no need for further action. They do not need to keep the patient alive, nor do they need to allow the patient to die. In this sense, one could argue that weak medical paternalism has no contradictions with allowing a patient to undergo voluntary euthanasia.

The relationship between strong medical paternalism and euthanasia is slightly more complicated. There are questions of a philosophical nature that must be addressed. For example, a strong paternalist would have to determine whether it is always objectively bad for a human to die, even if that human could prove that it was their desire to do so. In these cases, a physician may defer to morality or religion in order to make a decision. They would perhaps present the argument that even if a person wished to die, it would be an irrational desire and they should not indulge it. However, in the absence of these factors, it is possible for strong paternalism to be compatible with voluntary euthanasia. This would require the patient to make it clear that he or she would not be losing anything of value to them by dying, i.e. fundamentally disconnecting life from goodness. For example, if a patient learns that he or she would be in constant pain for the rest of his or her life, it is not irrational to honor their wishes to die. In these cases, some argue, even a strong paternalism does not justify prolonging the patient's life, because the physicians actions would not truly be for the patient's own good. [15]

See also

Related Research Articles

Euthanasia is the practise of intentionally ending life to eliminate pain and suffering.

<span class="mw-page-title-main">Informed consent</span> Process for obtaining subject approval prior to treatment or research

Informed consent is a principle in medical ethics and medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care. Pertinent information may include risks and benefits of treatments, alternative treatments, the patient's role in treatment, and their right to refuse treatment. In most systems, healthcare providers have a legal and ethical responsibility to ensure that a patient's consent is informed. This principle applies more broadly than healthcare intervention, for example to conduct research and to disclose a person's medical information.

<span class="mw-page-title-main">Assisted suicide</span> Suicide undertaken with aid from another person

Assisted suicide – alternately referred to as medical aid in dying – means a procedure in which people take medications to end their own lives with the help of others, usually medical professionals. The term usually refers to physician-assisted suicide (PAS), which is an end of life measure for a person suffering a painful, terminal illness. Once it is determined that the person's situation qualifies under the physician-assisted suicide laws for that location, the physician's assistance is usually limited to writing a prescription for a lethal dose of drugs.

In developmental psychology and moral, political, and bioethical philosophy, autonomy is the capacity to make an informed, uncoerced decision. Autonomous organizations or institutions are independent or self-governing. Autonomy can also be defined from a human resources perspective, where it denotes a level of discretion granted to an employee in his or her work. In such cases, autonomy is known to generally increase job satisfaction. Self-actualized individuals are thought to operate autonomously of external expectations. In a medical context, respect for a patient's personal autonomy is considered one of many fundamental ethical principles in medicine.

Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal. It is important to note that these four values are not ranked in order of importance or relevance and that they all encompass values pertaining to medical ethics. However, a conflict may arise leading to the need for hierarchy in an ethical system, such that some moral elements overrule others with the purpose of applying the best moral judgement to a difficult medical situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.

<span class="mw-page-title-main">Life support</span> In medicine

Life support comprises the treatments and techniques performed in an emergency in order to support life after the failure of one or more vital organs. Healthcare providers and emergency medical technicians are generally certified to perform basic and advanced life support procedures; however, basic life support is sometimes provided at the scene of an emergency by family members or bystanders before emergency services arrive. In the case of cardiac injuries, cardiopulmonary resuscitation is initiated by bystanders or family members 25% of the time. Basic life support techniques, such as performing CPR on a victim of cardiac arrest, can double or even triple that patient's chance of survival. Other types of basic life support include relief from choking, staunching of bleeding by direct compression and elevation above the heart, first aid, and the use of an automated external defibrillator.

The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, incurable pain, or without the will to continue living, should be allowed to end their own life, use assisted suicide, or to decline life-prolonging treatment. The question of who, if anyone, may be empowered to make this decision is often the subject of debate.

Futile medical care is the continued provision of medical care or treatment to a patient when there is no reasonable hope of a cure or benefit.

Voluntary euthanasia is the ending of a person's life at their request in order to relieve them of suffering. Voluntary euthanasia and physician-assisted suicide (PAS) have been the focus of intense debate in recent years.

The doctor–patient relationship is a central part of health care and the practice of medicine. A doctor–patient relationship is formed when a doctor attends to a patient's medical needs and is usually through consent. This relationship is built on trust, respect, communication, and a common understanding of both the doctor and patients' sides. The trust aspect of this relationship goes is mutual: the doctor trusts the patient to reveal any information that may be relevant to the case, and in turn, the patient trusts the doctor to respect their privacy and not disclose this information to outside parties.

Involuntary Euthanasia is currently illegal in all 50 states of the United States. Assisted suicide is legal in 10 jurisdictions in the US: Washington, D.C. and the states of California, Colorado, Oregon, Vermont, New Mexico, Maine, New Jersey, Hawaii, and Washington. The status of assisted suicide is disputed in Montana, though currently authorized per the Montana Supreme Court's ruling in Baxter v. Montana that "nothing in Montana Supreme Court precedent or Montana statutes [indicates] that physician aid in dying is against public policy."

Non-voluntary euthanasia is euthanasia conducted when the explicit consent of the individual concerned is unavailable, such as when the person is in a persistent vegetative state, or in the case of young children. It contrasts with involuntary euthanasia, when euthanasia is performed against the will of the patient.

Therapeutic privilege refers to the decision of a healthcare practitioner to withhold information from a patient when there is a justified belief that disclosure may cause serious mental or physical harm to them. As of 2022, this defence is permissible in countries such as Australia, Canada, England, Netherlands and Wales as an exception to the standard consent process. Despite this, there are very limited cases in which therapeutic privilege has been upheld. This is mainly due to the complex ethical and legal ramifications in withholding information from a patient and how to define someone as being at sufficient risk to fall into this category wherein therapeutic privilege should prevail. Another challenge in enacting therapeutic privilege is the consideration of other professionals involved in patient care, such as where there is a multidisciplinary care team. However, in withholding information, there is also a denial of patient autonomy

<span class="mw-page-title-main">Legality of euthanasia</span>

The legality of euthanasia varies depending on the country. Efforts to change government policies on euthanasia of humans in the 20th and 21st centuries have met limited success in Western countries. Human euthanasia policies have also been developed by a variety of NGOs, most notably medical associations and advocacy organizations. As of 2023, euthanasia is legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, Portugal, Spain and all six states of Australia. Euthanasia was briefly legal in the Northern Territory between 1996 and 1997, but was overturned by a federal law. In 2021, a Peruvian court allowed euthanasia for a single person, Ana Estrada.

Child euthanasia is a form of euthanasia that is applied to children who are gravely ill or have significant birth defects. In 2005, the Netherlands became the first country since the end of the Third Reich to decriminalize euthanasia for infants with hopeless prognosis and intractable pain. Nine years later, Belgium amended its 2002 Euthanasia Act to extend the rights of euthanasia to minors. Like euthanasia, there is world-wide public controversy and ethical debate over the moral, philosophical and religious issues of child euthanasia.

Both Euthanasia and Assisted Suicide are illegal in the United Kingdom and could be prosecuted as murder or manslaughter.

<span class="mw-page-title-main">Euthanasia in Canada</span> Legal history of euthanasia in Canada

Euthanasia in Canada in its legal voluntary form is called Medical Assistance in Dying (MAiD) and it first became legal along with assisted suicide in June 2016 for those whose death was reasonably foreseeable. In March 2021, the law was further amended by Bill C-7 which to include those suffering from a grievous and irremediable condition whose death was not reasonably foreseeable. According to the Fourth Annual Report on MAID, there were 13,241 MAID deaths reported in Canada in 2022.

<span class="mw-page-title-main">Raphael Cohen-Almagor</span>

Raphael Cohen-Almagor is an Israeli/British academic.

Critics of euthanasia sometimes claim that legalizing any form of the practice will lead to a slippery slope effect, resulting eventually in non-voluntary or even involuntary euthanasia. The slippery slope argument has been present in the euthanasia debate since at least the 1930s.

<span class="mw-page-title-main">Medical sociology</span> Branch of sociology

Medical sociology is the sociological analysis of medical organizations and institutions; the production of knowledge and selection of methods, the actions and interactions of healthcare professionals, and the social or cultural effects of medical practice. The field commonly interacts with the sociology of knowledge, science and technology studies, and social epistemology. Medical sociologists are also interested in the qualitative experiences of patients, often working at the boundaries of public health, social work, demography and gerontology to explore phenomena at the intersection of the social and clinical sciences. Health disparities commonly relate to typical categories such as class and race. Objective sociological research findings quickly become a normative and political issue.

References

  1. ↑ Brennan, Troyen (1991). Just Doctoring: Medical Ethics in the Liberal State. University of California Press. pp. 51–53.
  2. ↑ MPS. "The end of paternalism". www.medicalprotection.org. Retrieved 2017-04-15.
  3. ↑ "Consent guidance: Legal Annex - Common Law". General medical Council.
  4. 1 2 3 4 5 Kaba, R.; Sooriakumaran, P. (February 2007). "The evolution of the doctor-patient relationship". International Journal of Surgery . 5 (1): 57–65. doi: 10.1016/j.ijsu.2006.01.005 – via ScienceDirect.
  5. 1 2 3 Sisk, Bryan; Frankel, Richard; Kodish, Eric; Harry Isaacson, J. (September 2016). "The Truth about Truth-Telling in American Medicine: A Brief History". The Permanente Journal. 20 (3). doi:10.7812/TPP/15-219. ISSN   1552-5767. PMC   4991917 . PMID   27352417.
  6. ↑ De, Monya (2004-02-01). "Towards Defining Paternalism in Medicine". AMA Journal of Ethics . 6 (2). doi: 10.1001/virtualmentor.2004.6.2.fred1-0402 . ISSN   2376-6980.
  7. ↑ Cathell, Daniel Webster (1889). Book on the physician himself and things that concern his reputation and success (9th ed.). Philadelphia: F. A. Davis. pp. 176–179 – via Archive.org.
  8. ↑ Kline, Nathan S.; Sobin, Julius (August 25, 1951). "The Psychological Management of Cancer Cases". Journal of the American Medical Association . 146 (17) – via Archive.org.
  9. ↑ Szasz, T. S., & Hollender, M. H. (1956). "The Basic Models of the Doctor-Patient Relationship." Archives of Internal Medicine, 97, 585–592.
  10. ↑ Sokol, D. K. (1 December 2006). "How the doctor's nose has shortened over time; a historical overview of the truth-telling debate in the doctor-patient relationship". Journal of the Royal Society of Medicine . 99 (12): 632–636. doi:10.1258/jrsm.99.12.632. ISSN   0141-0768. PMC   1676322 . PMID   17139067.
  11. ↑ Childress, James F. (1982). Who Should Decide?: Paternalism in Health Care . New York: Oxford University Press. ISBN   978-0-19-503127-0.
  12. ↑ Robison, Wade L.; Pritchard, Michael S. (1979). Medical Responsibility: Paternalism, Informed Consent, and Euthanasia . Clifton, NJ: The HUMANA Press. ISBN   978-0-89603-007-7.
  13. ↑ Richards, Edward (2009-04-19). "Public Health Law Map - Beta 5.7". The LSU Medical and Public Health Law Site. Retrieved 2017-04-11.
  14. ↑ Rosenbaum, Lisa (2015-08-13). "The Paternalism Preference — Choosing Unshared Decision Making". New England Journal of Medicine. 373 (7): 589–592. doi: 10.1056/NEJMp1508418 . ISSN   0028-4793. PMID   26267618.
  15. ↑ Häyry, Heta (1998). Individual Liberty and Medical Control. Ashgate Publishing Ltd. pp. 28–39. ISBN   1-84014-572-2.
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