Consideration of paternalism involves the interactions of two principles of medical ethics—beneficence and respect for autonomy. Historically, beneficence has long retained primacy in medical ethics, and physicians have been able to rely almost exclusively on their own judgement about their patients' needs for treatment, information, and consultation. However, medicine has increasingly been confronted—especially since around 1970—with a different kind of need, namely the patient's asserted need to make an independent judgment.
The central problem in these discussions is whether the principle of respect for autonomy, which gives primary decision-making authority to patients, should have priority in medical practice over the principle of beneficence, which gives authority to providers to implement sound principles of health care. Resolving this issue requires coming to terms with the problem of paternalism. Medical paternalism poses significant moral questions because it holds that beneficence can legitimately take precedence over respect for autonomy. From this perspective, a professional is like a parent dealing with dependent, and often ignorant and fearful, patients.
For example, suppose an incurable cancer is found in a sixty-nine-year-old man. Based on a long relationship, the man's physician knows that the patient has a history of psychiatric illness and is emotionally fragile. When the patient blurts out, "Am I OK? I don't have cancer, do I?" the physician answers, "You're as good as you were ten years ago," knowing that the response is a paternalistic lie, but also believing it justified in protecting the health and well-being of the patient.
Some leading ethicists maintain that paternalistic interventions are seldom justified, because the right of the patient to act autonomously almost always outweighs obligations of beneficence toward the autonomous patient. In the practical world, it is important to seek a balance between the demands of both beneficence and respect for autonomy. It is useful to note that this balance may be seen differently in other cultures, where there may be a stronger tilt toward beneficence.
JOHN H. BRYANT
Beauchamp, T. L., and Childress, J. R. (1989). Principles of Biomedical Ethics. New York: Oxford University Press.
Veatch, R. M. (1989). Medical Ethics. Boston: Jones and Bartlett Publishers.