EDITORIAL: Paradoxes of retreat from paternalism
Beneficence and autonomy are, together with nonmaleficence and justice, basic principles of medical ethics. Beneficence is the duty to “do good” and implies doing right by patients.1 Autonomy, “which can be understood simply as self-determination, is based in the fundamental imperative of respect for persons.”1 As Dr. Laura Weiss Roberts1 noted, “Beneficence untempered by autonomy was and is often paternalistic, relying inordinately on the wisdom and conscience of the physician without sufficient regard for the perspective and values of the patient. Since the 1960s, as medical technology came to offer more for care and as society became more rights oriented, patients increasingly began to experience more authority in the process of making medical decisions. There has been a gradual and perceptible shift from beneficence as the keystone of medical ethics to autonomy as the dominant principle of bioethics in Western medicine.”
With this shift toward autonomy, the idea of paternalism is considered passé. As physicians, we are now expected to avoid any paternalism in our interactions with patients. We continue to forget that paternalism is not a black or white issue, but rather a term that is—and should be—nuanced. We frequently consider paternalism solely in terms of hard paternalism, forgetting that soft paternalism is permissible and should be used. Soft paternalism includes enthusiastically and convincingly advising the informed patient to undergo certain treatments or stopping a patient from completing suicide.
The availability of unlimited medical information on the Internet, together with the nearly complete retreat from paternalism, can place us almost in a position of a well-informed advisor rather than a treater or healer. As physicians, this is a position we are not used to, and not always comfortable with. I can think of at least 3 areas where this retreat from paternalism has unintended consequences with which we and possibly our patients and society should not be comfortable.
First, many people involved in decision-making about patient care (patients, families, mid-level health care personnel) like to advise and make decisions but rarely accept responsibility for negative outcomes. Rather, it is the physician who is always viewed as the individual responsible for negative outcomes, no matter how the treatment decision was reached. On the other hand, positive outcomes are considered a result of shared decision-making.
Second, as noted previously, autonomy is based in the fundamental imperative of respect for person.1 Although one would expect that this respect for person should be mutual, lately, I have felt that too often this is a one-way street. Some patients do not appreciate that behaviors such as not showing up for an appointment, arriving late, and asking for an immediate refill because “I ran out of my medication yesterday” are disrespectful. Unfortunately, it seems we are encouraging this behavior by not always addressing it head-on, possibly due to a fear of being paternalistic. But don’t our patients have responsibilities, too? Don’t we infantilize them by not requiring them to be responsible and respectful?
Finally, the near-complete retreat of paternalism probably contributes to the creation of what David H. Freedman2 aptly calls “the worst patients in the world.” Freedman asks whether the problems with the American health care system lie not only with the system but also with American patients. He has observed that patient behavior is responsible for much of the variation in health outcomes across the nation, and that patients are often demanding and want to dictate treatment decisions. He mentions an oncologist who said that patients would object to not getting the best possible (and probably most expensive) treatment, even if the benefit is measured not in extra years of life, but rather in months (p 29).2 Furthermore, “Most experts agree that American patients are frequently overtreated, especially with regard to expensive tests that aren’t strictly needed. The standard explanation for this is that doctors and hospitals promote these tests to keep their income high. This notion likely contains some truth. But another big factor is patient preference. A study out of Johns Hopkins’s medical school found doctors’ two most common explanations for overtreatment to be patient demand and fear of malpractice suits—another particularly American concern. In countless situations, such as blood tests that are mildly out of the normal range, the standard of care is ‘watchful waiting.’ But compared with patients elsewhere, American patients are more likely to push their doctors to treat rather than watch and wait” (p 29).2 In addition, “American patients similarly don’t like to be told that unexplained symptoms aren’t ominous enough to merit tests” (p 30).2 Here, Freedman cites another physician whose patients would demand laparoscopic surgery to investigate abdominal pain that would almost certainly have gone away on its own. Finally, American patients disregard routine care, end up in the emergency room more frequently than patients in other countries, and end up with specialty referrals more often than patients in other countries. Freedman concludes that “The American health-care system has problems, yes, but those problems don’t merely harm Americans—they are caused by Americans” (p 30).2 One wonders how much the retreat from paternalism has contributed to this situation … as these problems are not as pronounced in countries where what the doctor says still goes (p 30).2
It seems to me that the retreat from paternalism brings us some paradoxical, unintended consequences, and that the concept of complete autonomy and the retreat from paternalism may need some rethinking and re-conceptualization. I am not advocating a return to the old days of complete paternalism. I am just questioning whether the pendulum of our view of paternalism has not, as with many other things, swung too far. A certain degree of soft paternalism could help in many situations, whereas complete autonomy for patients may lead to anarchy.
Richard Balon, MD
Departments of Psychiatry and Behavioral
Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Drive
Detroit, MI 48201 USA
1. Roberts LW. A clinical guide to psychiatric ethics. Washington, DC: American Psychiatric Association Publishing; 2016:9.
2. Freedman DH. The worst patients in the world. The Atlantic. July, 2019:28-30. www.theatlantic.com/ magazine/archive/2019/07/american-health-carespending/ 590623/. Accessed September 5, 2019.