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Subject Area: Political Theory

Medical Paternalism vs. Autonomy - Leonard P. Liggio, Literature of Liberty, January/March 1979, vol. 2, No. 1 [1979]

Edition used:

Literature of Liberty: A Review of Contemporary Liberal Thought was published first by the Cato Institute (1978-1979) and later by the Institute for Humane Studies (1980-1982) under the editorial direction of Leonard P. Liggio.

Part of: Literature of Liberty: A Review of Contemporary Liberal Thought, 20 vols. 19781-982

About Liberty Fund:

Liberty Fund, Inc. is a private, educational foundation established to encourage the study of the ideal of a society of free and responsible individuals.


Medical Paternalism vs. Autonomy

Allen Buchanan

  • University of Minnesota, Minneapolis

“Medical Paternalism.” Philosophy and Public Affairs 7 (Summer 1978): 370–390.

lf0353-05_1979v1_figure_008

The medical paternalist model of the physician-patient relationship corrupts both medical practice and the patient's autonomy in deciding on medical treatment. The defective arguments propping up the medical paternalist's practice of withholding information from patients and their families reveals the flaws of the paternalist model. Furthermore the distinction between ‘ordinary’ and ‘extraordinary’ therapy is a symptom of the pervasive influence of the paternalist model.

Three arguments seek to justify withholding information from a patient or his family about a physician's diagnosis, and the possible treatments or risks of each kind of treatment. The first or “Prevention of Harm Argument” defends a physician's withholding information to minimize the harm alleged which bad news would work on the patient. Scant evidence ever supports this complex judgment, nor are the harms alleged wholly clinical or medical. Some invoke the Hippocratic Oath, which mentions preventing harm to patients to justify the paternalist withholding of information even from patients' families.

A second or “Contractual Version of the Prevention of Harm Argument” alleges that the patient, by contracting for a physician's services, authorizes that physician to withhold information which he judges would harm the patient. But clearly not all patients subscribe to this stipulation as part of their agreement with the physician. Since contract between physician and patient is conditional and limited, the patient is entitled to judge the physician's performance, and to terminate the relationship if in his judgment the physician has failed to live up to his obligations.

A third argument holds (particularly in treatments of defective newborns) that the physician alone can understand and unemotionally evaluate the consequences of alternate treatments. The physician is obligated to make a reasonable effort to make consequences of alternatives understood; he is not and cannot be obligated to succeed in making them understood. Moreover, this tends to nurture in patients and their families the very medical ignorance used to justify paternalism.

The medical paternalist view also governs the troublesome distinction between “ordinary” and “extraordinary” therapy. This distinction separates those treatments that do not involve any grave burden to the patient or another from those treatments that do. However, although medical practitioners may be qualified to judge the medical complexity of a treatment, they are not especially qualified to make the moral judgment of what is extraordinary or gravely burdensome to a patient. For the physician to usurp the patient's moral evaluation and decision of the kinds of therapy he may desire is to impose medical paternalism in place of personal autonomy.