Paternalism and Patient Autonomy

Paternalism and Patient Autonomy

On its face, the relationship between patient and health caxe plovlder seems technically simple and morally clear. The provider–physician, nurse, physician’s assistant, or other professional–has a duty of beneficence toward the patient, an ob- ligation to use her medical expertise to do him good and to avoid doing him harm. The patient has a right to this skilled beneficence and to re- spect for his autonomous choices regarding what the provider does. But below the surface, com- plications simmer. The principles of beneficence and autonomy are frequently at odds The val- ues of providers and patients can diverge. The cultures of patients, physicians, and nurses can clash. And often the stakes for everyone involved are extraordinarily high

In this chapter we explole several moral issues arising from these conflicts, focusing on ques- tions of medical paternalism, refusing treatment, and “futile” treatment Chapter 4 delves into other aspects of patient-provider relationships, notably truth-telling, deception, and confiden- tiality. Chapter 5 examines the patient-provider relationship further by studying the many sides of informed consent and patient competence.

SHADES OF AUTONOMY AND PATERNALISM

Autonomy is a person’s rational capacity for self- governance or self-determination. It is an individ- ual’s power to deliberate about available options, to choose freely among those posslbthtles, and to act accordingly. We fully exercise our autonomy when our choices and actions are truly our own, flee from the overriding pressure of people and factors that rob us of control. The requirement to

respect autonomy runs through all of bioethics, expressed in the autonomy principle, which we can state as autonomous persons should be allowed to exercise their capacity for self-determination. In bloethics it is considered a fundamental stan- dard that can be violated only for good reasons and with explicit justification. In the name of the autonomy principle, medicine has developed the doctrine of informed consent and has devised countless procedures and guidelines to ensure that the principle IS honoied in the details.

Limitations on a person’s autonomy can be physical or psychological, obvious or subtle, jus- tiffed or unjustified, and generally accepted or widely controversial. Physically restraining a pa- tient violates his autonomy, and so does misin- forming him about the seriousness of his illness. Forcing a healthy woman to have a hysterectomy is obvious coercion. Using false information to persuade her to have the operation is a subtler kind of compulsion. We tend to think that phy- sicians are sometnnes justified In confining and treating a mentally ill man who is a danger to himself and others. We would not think so if the man were perfectly healthy Giving a 12-year-old girl a blood transfusion to save her life seems hke normal medical practice. Withholding the trans- fusion because her parents say it is an affront to their religious faith is controversial.

Conflicts between respect for patients’ auton- omy and providers’ duty of beneficence usually raise the issue of paternalism, which we can de- fine as the overriding of a person’s actions or de- cision-making for hÿs own good. Early medical practice was strongly paternalistic, inspired by the Hippocratic tradition of devotion to the welfare of patients and fatherly insistence on deciding

 

 

72 PAR3 2″ HEDICAL PROPESSIONAL AND PATIENT Chapter 3. Patmnahsm and Patient Autonomy 73

unilaterally what is best for them. The Hippo- cratic Oath and many later professional codes of medical practice had much to say about obliga- tions to help and not to haim patients but little or nothing to declare about patients’ rights to de- cide about their own medical care But over the last few decades, this Mnd of heaw-handed pa- ternalism has abated as society has placed more value on the rights of patients to know important facts about their medical care, to make choices regarding their medical treatment, and even to refuse treatment that physicians recommend.

We can distinguish between two kinds of paternalism. Weak paternalism refers to pa- ternalism directed at peisons who cannot act autonomously or whose autonomy is greatly diminished–who may be, for example, danger- ously psychotic, severely retarded, extremely de- pressed, or acutely addicted Weak paternalism is not usually considered an objectionable vio- lation of autonomy because patients are already substantially nonautonomous to some degree Generally it is thought to be morally acceptable because its purpose is to protect people from harm while they are nonautonomous, to deter- mine if they are in fact nonautonomous, or to re- store them to full autonomy. Strong paternalism is the overriding of a person’s actions or choices even though he is substantially autonomous Cases involving strong paternalism often pro- voke debate and sometimes legal wrangling. A man who normally behaves autonomously and rationally IS involuntarily committed to a men- tal institution because he occasionally becomes confused and disoriented and doctors fear that he might someday become a threat to himself or others. A physician discovers that his patient has a malignant breast tumor, but because he knows she is terrified of the disease, he tells her that the tumor is benign and should be surgi- cally removed just in case A woman who needs a life-saving blood transfusion refuses it on reli- gious grounds, but when she lapses into a coma, surgeons operate and give her the transfusion anyway These and other scenarios play out more

often than we might think and prompt not only ethical disagreement but also personal and pro- fesslonal anguish.

Many people are staunchly antl-paternahstlc, condoning (as most do) acts of weak paternal- ism but rejecting all forms of strong paternalism. They argue that strong paternalism is wrong be- cause it violates the rights of persons to deter- mine for themselves what is good and what is right. Persons are sovereigns over their own lives, and overriding their sovereignty is impermissi- ble regardless of the benefits gained by violating it. Others are more willing to countenance some acts of paternalism (including strong paternal- ism) on the grounds that the persons revolved would consent to the acts if circumstances were ideal (if, say, the persons were thinking more ra- tionally). These thinkers, for example, might be willing to commit a substantially autonomous person to a mental institution involuntarily if he would have trouble living independently and might be a danger to himself. Still others argue that the only satisfactory justification for pater- nalism is not consent but beneficence–interven- ing simply to promote someone’s welfare. On this view, the benefits ofpaternahstic actions must be balanced against the importance of respecting autonomy. Actions that minimally restrict au- tonomy but benefit the person greatly would be justified; actions that seriously violate autonomy while offering only minor benefits would not be acceptable. Far less important would be concerns about what the individual would or would not consent to under different circumstances?

REFUSING TREATMENT

Patients want physicians to treat them; physi- cians want to treat patients. But often when patients (or their surrogates) refuse treatment, patient autonomy and physician beneficence collide, sparldng personal frustration and moral perplexity all around. In such cases the most vex- ing bioethical questions include: Is it ever mor- ally permissible for a physician to treat a patient

For centuries the Hippocratic Oath has been one of the great mspwauons for Western medmal etNcs It is one of several writings attributed to an ancmnt Greek school of medicine whose head was Hip- pocrates, born about 460 B C.

I swear by Apollo Physmlan and Asclepius and Hy#eia and Panaceia and all the gods and god- desses, making them my wimess, that I will fulfill according to my abdlty and ludgment tNs oath and tNs covenant:

To hold him who has taught me this art as equal to my parents and to hve my life in partnershtp wÿth hm, and ff he Is m need of money to give him a share of mine, and to regard Ns offspring as equal to my brothers m male hneage and to teach them tNs art–if they deswe to learn tt–wJthout fee and covenant;

to give a share of precepts and oral mstructton and all the other learning to my sons and to the sons of Nm who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medmal law, but to no one else

I will apply dJeteuc measures for the benefit of the sml< according to my ability and ludgment; I will keep them from harm and mlUSUCe.

I will neither #ve a deadly drug to anybody if asked for ut, nor wdl I make a suggesUon to tNs effect. Similarly I will not give to a woman an aboruve remedy. In purity and holiness I will guard my hfe and my art

I will not use the knife, not even on sufferers from stone, but will withdraw m favor of such men as are engaged m this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all mten- uonal mlusuce, of all mtscNef and m parucular of sexual relauons with both female and male per- sons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment m regard to the life of men, whmh on no account one must spread abroad, I wdl keep to myself holding such things shameful to be spoken about

If I fulfill tNs oath and do not wolate ÿt, may it be granted to me to enloy hfe and art, being honored with fame among all men for all ume to come; ff I transgress it and swear falsely, may the opposite of all this be my lot.

From Ludwig Edelstem, Ancient Medicine Selected Papers of Ludwig Edelstem, ed Owsel Temkm and C Ldhan Temkm (Baltimore Johns Hopkins Umverslty Press, 1967), 3-65

against her will? If so, what justifies the action, and under what conditions is it acceptable?

Until the late 1980s, the right of competent pa- tients to turn down treatments ordered by phy- sicians was unsettled. (Very roughly, competent patients are autonomous persons able to make decisions about treatment options.) In some situ- ations, patients were thought to have no right to dedine recommended treatments. Physicians sometimes forced pregnant patients to have ce- sarean deliveries if failure to do so put the fetuses at extreme risk. The courts frequently overruled the right to refuse treatment if the patient had

dependent children or if the patIeut was not ter- minally 111. But later court rulings reversed the trend and carved out the bedrock principle that a competent patient has a right to reject recom- mended treatments, even life-saving ones. The legal principle now parallels the prevailing view in bioethlcs, which shifts the weight to patient au- tonomy over physician and nurse beneficence.

• he courts have also stretched this right of competent patients to situations in which they be- come incompetent, as when they lapse Into coma. Through advance directives or other evidence of their preferences, they can refuse life-sustaining

 

 

7 4

P A

R T

2 : H

E D

IC A

L P

[ÿO F

E ÿS

IO N

A L

A N

D P

t= ÿ|IE

N T

A ÿa

p te

r 3 , P

a ÿe

ÿm h

sm a

n d

P a

, tm n

t A u

to n

o m

y 7 5

tre a

tm e

n t T

h ts e

xp re

ssto n

o f p

rio r in

te n

tio n

s is now

w idely recognized as a legitim

ate exercise of autonom

ous choice. The right to refuse treatm

ent seem s a relatively

stt aightforw ard issue w

hen the patient is a com pe-

tent adult, but w hat if the patient ts a child w

hose p

a te

n ts re

je ct th

e re

co m

m e

n d

e d

m e

d tca

l tre a

t- m

ent on religious grounds? C onsider the case of

ll-ye a r-o

ld Ia

n L

u n d m

a n o

f M m

n e a p o h s, M

m –

nesota, w ho dted on M

ay 9, 1989, after shpplng into a diabetic com

a H ts diabetes had rem

ained m

edically untreated, his m other and stepfather

forgoing insulin in favor of prayels from C

hris- tian S

cience practlttoners.2 (C hristian S

cientists believe that disease is a spiritual &

sorder requir- ing spm

tual healing, not m edical treatm

ent.) O r

constder thts scenario, typical of such cases: A 6-

year-old girl is seriously injured m a traffic acci-

dent, and the only w ay to save her life ts to give hm

a blood transfusion–w hich her Jehovah’s W

itness parents reject because the procedure is explicitly forbidden by their faith. The physicians proceed w

ith the transfusion and save the gnl’s life, and the patents sue the physicians and the hospital.

P arents w

ho for religious reasons reject m edi-

cal treatm ent foi their children m

sist on the right to &

ode w hat’s best for them

and sincerely be- lieve w

hat’s best ts avoiding m edical interven-

tions. 3hey dem and the freedom

to practice their rehgton as they see fit. B

ut others have argued (including the courts) that though parents m

ay decide m

any m atters on the w

ell-being of their children, they do not have the right to bring se- rious harm

to them , especially since children

cannot decide such tssues for them selves. T

his view

w as sum

m ed up in a fam

ous 1944 S uprem

e C

oult dectsion: “P arents m

ay be free to becom e

m altyrs them

selves. B ut tt does not follow

they a te

fre e ., to

m a ke

m a rtyrs o

fth m

r ch ild

re n :’3

T he sttuatlon takes on a different hue w

hen children are considered com

petent to decide for them

selves. S tates dtffer on w

hether an adoles- cent can be a “m

ature m inor” to m

ake health de- cisions, and the courts have w

affled on the issue Judges have ruled, for exam

ple, that a 15-year-old Jehovah’s W

itness gift dying of leukem ia could

refuse a blood transfuston that w ould save her

life –b

u t th

a t a

1 6 -ye

a r-o

ld b

o y in

ju re

d m

a tra

in accident could not decline a transfusion needed d u rin

g su

rg e ry to

sa ve

h is a

rm . N

e ve

rth e le

ss, m

a n

y a rg

u e

th a

t if a d

o le

sce n

ts a re

n o

t co m

p e

– tent to dectde such things, com

petent adults (in- cluding phystcians and nurses) should step tn to p

ro te

ct th e

ir w e

lfa re

, e ve

n if m

te rve

n ln

g m

e a

n s

defying religious doctrine.

F U

T ILE

T R

E A

T M

E N

T

The classic pattern ofpatei nahsm involves a phy-

sician w ho w

ants to treat a patient w ho prefers

not to be treated. B ut som

ehm es things happen

th e o

th e r w

a y a

ro u n d –w

h e n th

e p

a tie

n t o

r th e

patient’s fam ily w

ants a tIeatm ent that the phys>

ctan, typtcally fiom beneficent m

otives, does not w

a n

t to p

ro vid

e . T

h e

m a

in m

o ra

l co n

flict is b e

– tw

een patient autonom y and the physician’s view

of w hat constitutes m

oially acceptable care. The m

ost dram atic (and heart-rending) of such

cases center on w hether to supply hfe-sustaxnlng

tteatm ent to the pattent. C

onstder the m uch dis-

cussed story of 85-year-old H elga W

anglie, w ho

in 1990 suddenlyhad to be placed on a ventilator because of serious breathing problem

s. O ver the

follow ing w

eeks, her condition w orsened as she

sank into unconsciousness and then into a per- ststent vegetattve state (a deep com

a that is usu- ally lrrevelsible). S

he received round-the-dock hfe-sustalnlng tieatm

ent consisting of ventilator, a

n tib

io tics, tu

b e

fe e

d in

g s, a

n d

o th

e r m

e a

su re

s B

ut physictans told H elga’s husband and tw

o children that the treatm

ent w as not helping her

and should be stopped. H er fam

ily, how ever, de-

m anded that the treatm

ent continue. They hoped for a m

iracle and asserted that H elga w

as not bet- ter off dead and that physlctans should not play G

od. H er husband clatm

ed that H elga had never

exD essed an opinion about life-sustainm

g treat- m

ent for heiself. Later a second team of physi-

cians confirm ed the view

s of the first, calling the ve

n tila

to r “n

o n b e n e ficta

l” b e ca

u se

It co u ld

n o t

ease H elga’s sufferm

g, repatr her body, or help her experience life.

R e

fu s in

g T

re a

tm e

n t fo

r C h

ild re

n o

n R

e lig

io u

s G ro

u n

d s

S ince the 1970s, several chddren have dm

d after thew parents refused m

edm al treatm

ent because of reh- gious behefs. The deaths have sparked fierce debates and legal confhcts, w

ith som e lurtsdtcuons offering

rehgious parents exem puons from

child abuse and neglect law

s w hde m

edical orgam zauons such as

the Am erm

an Academ y of Pedlam

cs (AAP) and the A

m erm

an M edm

al A ssoclauon (A

M A

) have opposed the law

s In its pohcy statem ent on the ÿssue, the

A A

P declares, “C

onsutuuonal guarantees of free- dom

of rehglon do not perm it cN

Idren to be harm ed

through rehgJous pracuces, nor do they allow reh-

glon to be a vahd defense w hen an Individual harm

s or neglects a cN

Id.” A ccording to a recent tally of the

religious exem puons.

T hw

ty-nm e states and the D

Istrm t of C

olum N

a have rehglous exem

ptions m their ow

l codes on child abuse or neglect, largely because of a federal governm

ent policy from 1974 to 1983

requw m

g states to pass such exem ptions in

order to get federal funding for child protecuon w

ork The states are A labam

a, A laska, A

H zona,

A rkansas, C

aliform a, C

olorado, C onnecucut,

D elaw

are, Florida, G eorgia, Idaho, Illinois,

Indiana, Iow a, K

ansas, K entucky, Louisiana,

M aine, M

m N

gan, M innesota, M

ississippi, M

issouri, M ontana, N

evada, N ew

H am

pshw e,

N ew

Jersey, N ew

M exico, N

orth D akota,

O ldahom

a, O regon, P

ennsylvania, R hode

Island, S outh C

arohna, U tah, V

erm ont, V

w gm

la, W

ashington, W isconsin, and W

yom ing

A dditionally, Tennessee exem

pts caretakers

w ho w

ithhold m edical care from

being adludm

ated as negligent ff they rely instead on nonm

edm al “rem

edial treatm ent” that Is “legally

recogm zed or legally perm

itted.” N

ineteen states have rebgÿous defenses to felony crim

es against chddren A rkansas,

D e

la w

a re

, Id a

h o

, In d

ia n

a , Io

w a

, K a

n sa

s,

Lom slana, M

innesota, N ew

Jersey, O hm

, O

ldahom a, O

regon, R hode Island, Tennessee,

U tah, V

lrgm m

, W ashington, W

est V irginia, and

W isco

n sin

Eleven states have rehgÿous defenses to m

isdem eanors A

labam a, A

laska, C ahfornla,

C olorado, G

eorgia, N am

e, N evada, N

ew H

am pshm

e, N ew

Y ork, S

outh C arohna, and

S outh D

akota M issouri exem

pts parents from the m

ÿsdem eanor charges of endangerm

ent and nonsupport ff they provide “nonm

edm al rem

edial treatm

ent recognized and perm itted under the

law s of thÿs state” instead of m

edm al care

Florida has a rehgJous exem puon only m

the ow

l code, but the F lorida S

uprem e C

ourt nevertheless held that ÿt caused confusion about crim

inal habdW and requm

ed overturning a felony convÿcuon of C

hnsuan S oenusts for

lem ng them

daughter die of untreated dm betes

S tates w

ÿth a rehgious defense to the m ost serious

crÿm es against children include’

• Iow a and O

hto, w ith religious defenses to

m anslaughter

• D elaw

are and W est V

w gm

ta, w tth rehglous

defenses to m urder of a chtld

• A rkansas, w

ÿth a rehgious defense to capital m

urder • O

regon, w ith a rehgtous defense to hom

m lde

by abuse4

T he struggle over w

hether to dlscontm ue

H e lg

a ‘s tre

a tm

e n t e

ve n tu

a lly m

o ve

d in

to co

u rt,

but its decision did little to resolve the stalem ate.

Three days after the court ruling, H elga died.s

S uchphysician-patlent conflicts are com

m only

described as confrontations about m edical futil-

ity, the alleged pom tlessness or ineffectiveness of

a d

m m

tste rln

g p

a rticu

la r tre

a tm

e n

ts. P h

ysm ia

n s

 

 

76 P

A R

T 2

. N E

D IC

A L

P R

O F

E S

S IO

N A

L A

N D

P A

I’IE N

T C

h a p te

r 3 ‘ P

a L e Jrÿa

h sm

a n d P

a tm

rlt A u to

n o rn

y 1 7

T he m

edical procedure used to restart a person’s heart and breathing is know

n as cardlopulm onary re-

suscitation, or C P

R . It typically consists of m

outh-to- m

outh resuscitation and external chest com pression

but m ay involve m

ore advanced procedures such as defibrillation (electric shock to restore norm

al heart rhythm

). A do-not-resuscitate order, or D

N R

, is a dw

ectlve telling the m edical staff to forgo C

P R

on a patient ff hÿs heart or breathing stops D

N R

or-

ders are generally thought to be m edically appropri-

ate and m orally perm

issible w hen the perform

ing of C

P R

on seriously or term inally Ill patients w

ould be ineffective or futile and w

ould only prolong dying or intensify the patient’s pain and suffering. P

atients can co

n se

n t to

D N

R o

rd e

rs m p

e rso

n , m

w ritte

n in

stru c-

tions m an advance dw

ectÿve such as a hw ng w

ill, or through som

eone they designate as thew representa-

tw e, or proxy The A

H A

declares, “The physm B

an has an ethm

al obhgation to honor the resuscitation pref- erences expressed by the patient. P

hyslaans should not perm

it thew personal value judgm

ents about quahty of hfe to obstruct the im

plem entation of a

patient’s preferences regarding the use of C P

R ”

a s u

se le

ss, o r th

e p

a tm

n t d

ie s. B

u t so

m e

tim e

s resolution eludes everyone. The sharpest clash of values is likely to occur betw

een physicians and those w

ho argue for the sanctity of hum an life

O n this view

, the m oral im

perative is to keep the body alive at all costs. For som

eone w ho accepts

this principle, the physicians’ claim that the treat-

m ent does not benefit the patient w

ill carry little w

eight. A com

m on argum

ent against the position is that It m

akes no sense to treat a body w hen the

person w hose body it is no longer exists.

The m ajor m

oral theories im ply diverse stands on

paternalism . A

s a theory driven by the principle of beneficence, utilitarianisin dem

ands that w e

m a xim

ize th

e g

o o d fo

r e ve

ryo n e in

vo lve

d –a

re –

quirem ent that m

ay justify paternalistic actions. T

o p

ro m

o te

th e

g re

a te

st g o

o d

fo r p

a tie

n ts–to

m in

im ize

su ffe

rin g a

n d m

a xim

ize w

e ll-b

e in

g –a

physician or nurse m ay think it som

etim es legiti-

m ate to breach confidentiality or m

islead patients about their condition or proposed treatm

ent. S he

m ay believe it m

orally perm issible to override a

patient’s refusal of treatm ent or to reject the use

of requested treatm ents thought to be futile.

A ct- a

n d

ru le

-u tilita

ria n

s ca n

d isa

g re

e d

ra –

m atically on such m

atters. (They m ay also differ

m ay claim

that a treatm ent IS

futile and there- fore should not be used or continued. P

atients or their surrogates m

ay reject the label of futihty and insist that everything be done that can be done. B

ut physicians and patients often have different ideas about w

hat constitutes futility. The form er

m ay judge a treatm

ent futile if it cannot achieve a specified physiological benefit (cannot, for exam

ple, repair tissue, restore functioning, or ease suffering); the latter m

ay think a treatm ent futile

only if it cannot keep the body alive. For both, the issue of futility is a question of values–of w

hat should be done in the circum

stances. In tugs of w

ar over the acceptability of treat- m

ent, physicians appeal to a w idely recognized

principle: P hysicians are not obligated to pro-

vid e

tre a

tm e

n ts th

a t a

re In

co n

siste n

t w ith

re a

– sonable standards of m

edical practice. They are not m

orally bound to com ply, for exam

ple, w hen

a patient requests that his legs be am putated for

no reason or dem ands injections of a w

orthless and dangerous cancer rem

edy. N ot every patient

request m ust be regarded as legitim

ate, and not every m

edical technology m ust be supplied.

M any tim

es in futility cases, physicians and surrogates find resolution. T

hey agree to an exten- sion of the treatm

ent for a specified period or to reasonable goals that the treatm

ent can achieve, or the surrogates eventually view

the treatm ent

?%

C rm

cally im portant bloethm

al issues can arise for nurses from

thew relatÿonsN

ps w ÿth patm

nts, w ÿth

physicians, and w ith the institutional ethm

under w

hich they serve A

s nurses interact w ith patm

nts, they m ust com

e to term

s w ith m

any of the sam e m

oral questions and principles that w

m gh so heaw

ly on physicaans’ be- neficence versus patm

nt autonom y, patÿent-prow

der confidentiality, truth-telhng, refusal of treatm

ent, in- form

ed consent, and futde treatm ent.

The issues generated from physm

lan-nurse rater- actions can be just as pressing. The tradm

onal notion of a nurse ÿs that of a caregÿver subordinate to physi- cians and duty bound to carry out their dw

ectw es

for patm nt care and treatm

ent. B ut for m

any nurses

this m odel seem

s fraught w ith confhcts betw

een the nurse’s obhgatlon to follow

the doctor’s orders and her duty of beneficence tow

ard her panents S he m

ay w

onder w hether she has this sort of duty to physi-

cians even w hen thew

orders seem clearly to be Jn

error, or hkely to harm her patm

nts, or obw ously m

violation of patients’ autonom y, or ew

dently contrary to w

ell-established standards of care. S

o m

e w

rite rs h

a ve

d e

fe n

d e

d th

e tra

d itio

n a

l m

odel of nursing, arguing that (at least m hospitals)

physm lans m

ust alw ays be the ultim

ate authority on treatm

ent in urgent or serious cases. A fter all, only

doctors have the reqm slte training and experience

to deal w ith such situations, and for the sake of effi-

ciency, thew decisfons should not be quem

oned. The nurse’s proper role Is therefore subservient

B ut others reject the tradm

onal m odel, arguing m

– stead that the nurse’s ultim

ate responslbdlty is to be an advocate for patients, that adopting a subserw

ent role w

ould hkely harm patients, and that blindly follow

ing physm

ians’ orders does not serve the patient w ell

in theii estam ates of the probablhties involved and

ideas about the nature of the good to be m ax>

m ize

d .) In

a ct-u

tilita ria

n ism

, th e

iig h

tn e

ss o f a

c- tions depends on the relative good produced by in

d ivid

u a

l a ctio

n s, in

ru le

-u tilita

ria n

ism , rig

h t-

ness depends on the good m axim

ized by rules governing categories of actions. O

n act-utilitaiian grounds, a physician m

ay judge that it is m orally

perm issible to lie to a patient about a beneficial

treatm ent to overcom

e the patient’s refusal to be treated. B

ut based on rule-utihtarianlsm , a physi-

cian m ay believe that in the long run, lies do m

ore harm

than good because they erode public trust in the m

edical profession. B etter to adhere to a

rule barring deceit as a m eans of getting patients

to accept a treatm ent.

U tilitarians w

ho follow John S

tuart M all’s lead,

how ever, w

ould reject such paternalism . M

all be- lieves that the principle of utility im

plies a strong respect for individual self-determ

ination and as- se

rts th a t n

o o

n e m

a y in

te rfe

re w

ith a

p e rso

n ‘s

liberty except to prevent harm to others A

s M ill

says, “[A person] cannot nghtfully be com

pelled to do or forbear because it w

ill be better for him to

d o so

, b e ca

u se

It w ill m

a ke

h im

h a p p ie

r, b e –

cause, in the opinion of others, to do so w ould be

w ise, or even right”6 O

n this view people should

typlcaU y be perm

itted to decide w hat is to be

d o

n e

to th

e ir o

w n

b o

d ie

s, to re

fu se

tre a

tm e

n ts,

and to give their Inform ed consent.

G enerally, K

antian ethics also rejects pater- n

a h

sm . T

h e

m e

a n

s-e n

d fo

rm o

f th e

ca te

g o

rica l

im perative insists on respect foi the rights and

a u to

n o m

y o f p

e rso

n s–re

sp e ct th

a t m

u st n

o t b

e w

eakened by calculations of utility and paternal- istic urges to act for the patient’s ow

n good. T he

principle w ould require physicians to honor a

patient’s decision to refuse treatm ent, even w

hen they believe the treatm

ent is life-saving. Inform ed

consent of the patient for any treatm ent w

ould be m

andatory, and m isleading the patient about

treatm ent w

ould be out of the question. T o ignore

 

 

1 8 P

A R

t 2 : 1

“4 E

D IC

A L P

R O

F E

S S

IO N

[A L A

ÿD P

A T

![ÿN T

C h

a p

te r 3

‘ P a

te }n

a h

sm a

tÿd P

a tie

n t A

u to

n o

m y 1

9

E lizabeth B

ouvia

//

into her nose to her stom ach, a procedure know

n as nasogastrm

feeding. O pm

lons am ong m

edical pro- fesslonals about the practice w

ere m ixed, w

ith som e

saying that it w as necessary and others that tt w

as horrible and coercive, am

ounting to battery. B

ouvta lost an appeal of the ludge’s decision, w as

later transferred to another hospital, and eventually ended up at H

igh D esert H

ospital, a public long-term care faclhty. A

t H igh D

esert, her physicians ordered, against her w

ill, that she be once again force-fed to head off possible starvation. They thought nasogasm

c feeding appropriate because her condition w

as life- threatem

ng and because w ith adequate nutrition she

could possibly live another 15 or 20 years. S

he sued the hospital, askm g the S

uperior C ourt of

Los A ngeles to order the force-feeding halted. B

ut the court refused, saying that she clearly intended suicide and that the state could do w

hatever w as necessary

to preserve her hie. S

he appealed the decision to a higher court and, this tim

e, w on In a 1986 ruling, the C

alifornia C ourt of

A ppeal declared unequw

ocally that com petent adults

have a “constitutionally guaranteed right” to decide for them

selves w hether to subm

it to m edical treatm

ents:

[S ]uch a pauent has the right to refuse any m

edi- cal treatm

ent, even that w hich m

ay save or pro- long her hfe.. T

he right to refuse m edical treat-

m ent IS

basic and fundam ental. It IS

recogm zed as

a part of the right of prw acy protected by both

th e

sta te

a n

d fe

d e

ra l co

n su

tu u

o n

s. Its e xe

r-

cise requw es no one’s approval. It is not m

erely one vote sublect to being overridden by m

edm al

opinion .. A long hne of cases, approved by the

S uprem

e court m C

obbs v. G rant (I 972)… have

held that w here a doctor perform

s treatm ent

m the absence of reform

ed consent, there m s an

actionable battery. T he obw

ous corollary to tN s

principle m s that “a com

petent patient has the legal right to refuse m

e& cal treatm

ent”7

T he central issue in this fam

ous case–both m oral

and legal–Is w hether a com

petent pauent has the right to refuse hfe-sustaining m

edm al treatm

ent In gO

U V

la v S uperior C