Autonomy and paternalism

Question 1

What is ethics?

Answer 1

Ethics is about deciding what to do. It is not about opinions. In ethics, we need to find reasons to support why we should or shouldn’t do something.

Question 2

What is good ethical reasoning?

Answer 2

• Identify an argument to do something or not to do something.
• Assess whether the argument is relevant.
• Test the argument e.g. consider consequences.

Question 3

What is the ethical tree?

Answer 3

Focuses on THREE CONSIDERATIONS when making a decision – consequences, duty and virtue (the kind of person you want to be e.g. you want to be honest).

Question 4

What is consequentialism in ethics?

Answer 4

An action is ethically right if it brings about the best foreseeable consequences.

Question 5

What is utilitarianism?

Answer 5

It is a form of of consequentialism which states that the right action is that that brings about the maximum overall happiness. Utilitarianism requires us to take the actions which save the most lives or reduce the most suffering.

Question 6

What are the problems with just thinking about consequences in ethical decision making? (x6)

Answer 6

• Certain actions are (almost) always wrong
• Irrelevant whether the decision maker is a good or bad person i.e. does it not make a difference if the decision is being made by a bad person? Shouldn’t we also consider whether the person is good and has good intentions? Consequences ONLY considers the OUTCOME. We should also consider the who, what… etc.
• Very difficult to be certain of the consequences
• Does not respect individuals
• Does not recognize justice as morally valuable in itself
• Consequences can be used as a mask for something heinous.

Question 7

What is duty in ethics? In what circumstances does it challenge other principles in the ethical tree?

Answer 7

• Duty describes what you should do in the capacity of your role i.e. expectations. For example, the Hippocratic Oath.
• According to duty-based theories, certain actions are right or wrong in themselves irrespective of the consequences e.g. duty not to kill, a duty to tell the truth.

Question 8

What does deontological refer to in ethics?

Answer 8

The morality of a decision should be based on whether that decision itself is right or wrong under a series of rules (e.g. do not kill, do not lie…), rather than based on the consequences of the action. In other words, it describes duty.

Question 9

What is the benefit of considering duty in ethical decision making?

Answer 9

Does not require prediction of consequences of an action.

Question 10

What are the problems of considering duty in ethical decision making? (x3)

Answer 10

• How do we decide which actions are right and which are wrong?
• What do we do if our moral duties conflict?
• Absolves the individual from any moral responsibility for the consequences of their actions even if the consequences are very bad e.g. woman knocks on your door to hide from knife-wielding ex-husband. According to your ‘duty’, you let her in. Soon after, the husband comes knocking, asking to know if his wife is inside. Your ‘duty’ is to tell the truth – but this would cause harm to the wife.

Question 11

Why don’t we lie to patients? (x6) Think about the ethical tree.

Answer 11

• Might get found out – consequence. Might get struck off the GMC – consequence.
• Patients would lose trust – consequence.
• Duty to tell the truth – duty.
• Want to be honest – virtue.
• People need to know the truth to make decisions for themselves – duty to respect patient autonomy.

Question 12

What is meant by virtue in ethical decision making?

Answer 12

A virtue is a character trait a human being needs to flourish or live well and can be nurtured and developed. According to ethics, the best life of a human consists in the exercise of the virtues e.g. honesty, integrity, wisdom, fairness, compassion.

Question 13

What is autonomy?

Answer 13

Being free to make one’s own choices in life.

Question 14

What are the two values of autonomy?

Answer 14

Autonomy has INSTRUMENTAL value – I know what is best for me; and INTRINSIC value – it’s my life, I should have freedom to make my own decisions as a right. Without free will, we do not have moral responsibility.

Question 15

What is bodily autonomy and its significance?

Answer 15

Bodily autonomy is perhaps most important because it is the most intimate and personal part of one’s life. Respecting bodily autonomy is of particular importance!

Question 16

Emily Evans is 47 and has end stage renal failure. Her Husband was killed in a car crash 3 years ago. She tells her renal physician that she does not want hemodialysis and wants symptomatic treatment only. She understands that without dialysis she will die. Her 2 adult children are unable to persuade her to change her mind. Why should her autonomy still be respected?

Answer 16

here is more to well-being than medical well-being so best medical interests are not necessarily the same as best interests. Therefore, a bad health choice may still be in her overall best interests. Even if she is wrong about her best interests, being able to choose what is done to her own body is central to her autonomy. Provided she has been fully informed, has capacity to understand the arguments presented to her and provided with a reasonable range of choices, autonomy must be respected.

Question 17

What does respecting autonomy look like in clinical practice? (+7 considerations to enable this)

Answer 17

Respecting autonomy does not simply mean handing over decision making to the patient. It means RESPECTING AUTONOMOUS CHOICES. Enabling these autonomous choices means that a doctor must provide:

• Adequate information
• Clear information
• Providing a reasonable range of choices.
• Time to consider options.
• Not unduly pressurize patient.
• Being non-judgmental.
• Remember, not all choices are autonomous – this is known as paternalism.

Question 18

Why is respecting autonomy good for medical care? (x5)

Answer 18

• Help doctors give better advice
• Improve shared decision making
• Improve confidence
• Improve trust
• Improve adherence

Question 19

In what circumstance can power be exercised over patient’s autonomy?

Answer 19

The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good either physical or moral is not enough warrant e.g. banning drink driving or withholding bad news.

Question 20

What is the concept of overriding autonomy?

Answer 20

Paternalism - based on the belief that to do so is in their BEST INTERESTS.

Question 21

What is paternalistic dishonesty?

Answer 21

Withholding information from a patient or lying to them – usually in an attempt to meet best interests of patient.

Question 22

What arguments are there to justify paternalistic dishonesty? (x3)

Answer 22

• Technical information is difficult to put across – patients may not understand or may put undue weight on rare complications of treatment.
• Doctors face uncertainty – life expectancy or outcome of a treatment may be unpredictable.
• The patient might not be able to handle the information – might make him worse e.g. telling patient a procedure may panic patient. Saying to them that something is not going to hurt is the typical paternalistic dishonesty seen in medicine.

Question 23

What are the problems with paternalistic dishonesty in medicine? (x3) Think about the ethical tree.

Answer 23

• Paternalistic dishonesty is RARELY JUSTIFIED.
• CONSEQUENCES: most patients want to be told their diagnosis; many patients with a serious illness suspect their diagnosis before they are told anyway; patients may not trust doctor if they feel their doctor is not being honest with them. In other words, what if our sense of moral right and wrong is misguided, and what we believe is in the best interests of the patient is actually not e.g. withholding information that we think would harm patient, but in reality, patient doesn’t care about bad news – their priority instead is knowing everything!
• DUTY TO RESPECT AUTONOMY: knowing the diagnosis and prognosis is important for making other important decisions.
• VIRTUE: honesty is an essential virtue of doctors.

Question 24

Is lying worse than withholding the truth? (x5 and x4)

Answer 24

• YES, because: (i) withholding info restricts autonomy less, (ii) patients may also not want to hear bad news, but never want to be lied to, (iii) impossible to tell patients everything, (iv) less likely to cause mistrust, (v) there is an absolute moral duty not to lie.
• NO, because: (i) if intention is the same, then withholding is morally equivalent, (ii) wrong to assume patients don’t want to know, (iii) will cause mistrust, (iv) moral duty to withhold info that you know would be important to the patient.