Liberty and Paternalism in Medical Ethics
The basic “rule” of paternalism is that as an adult, you have the right to make decisions. However, paternalism’s harm principle states that we are “justified in restricting someone’s freedom to act if doing so is necessary to prevent him from hurting himself.” When Rawls says that “each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all” he is approving a mild form of paternalism in that the bartering away of liberty for social or economic benefits should be prohibited. It is this very harm principle that joins the concept of liberty and paternalism.
In Miller’s article, “Autonomy and the Refusal of Lifesaving Treatment” he outlines four cases that show the inconsistent decisions of the treating physicians in regard to patient autonomy. In the first case, a retired doctor experienced a cardiovascular collapse after he was treated for advanced carcinoma. He made his desire to not be resuscitated known to the hospital by signing a waiver that was placed in his file. Two weeks later, he suffered a heart attack and against his wishes, his heart was restarted five times in one evening. To add insult to injury, plans were made to place him on a respirator even after his heart had stopped altogether.
The second case was of a 43-year old man who was admitted to the hospital with severe injuries after a tree had fallen on him. He was told that he would need a whole-blood transfusion which he denied because of his faith (Jehovah’s Witness). After much legal discussion and counsel, the hospital agreed to respect his autonomy and he was not treated with a transfusion.
In the third case, a 38-year old man was admitted to the hospital with a diagnosis of bacterial meningitis. If treatment is sought quickly, this is an illness that can be combated, however when the physician urged the patient to make a swift decision, he said he wanted to be allowed to die. This article isn’t clear about the actual outcome except to say “there is no apparent reason to justify the death of this otherwise healthy victim of meningitis.”
The fourth case discusses a 52-year old man who was admitted to the hospital after he intentionally ingested an unknown quantity of diazepam. While he suffered from multiple sclerosis, it was clear that he had sufficiently adapted to the condition and had been leading a relatively productive life until a few months prior when he slipped into a state of severe depression. When he “came to” in the emergency room, he expressed that he wanted to be allowed to die with dignity. A psychiatric consultation was scheduled and it became evident that his suicide attempt was really a cry for help and attention as his wife and children had been paying more attention to his mother-in-law who had just received a diagnosis of inoperable cancer. His attempt to die happened on the first night they had left him alone to be with her. It’s obvious that this patient’s request to die was ignored.
Because Kant is interested in universal actions and is focused on the objective rather than the subjective in a situation, I believe he would have made different decisions in the above cases. Kant cares about motives – not results. I believe that by applying his maxim that you should never treat another person as a means only, you would find that he would further examine the motives of the patients in making their decisions and use that as his basis. I believe that in cases one and two, Kant would have respected the autonomy of the patients, but that in cases three and four, he would have found the motives weak.
As Mill is interested in the “greater good,” I believe he would have ignored the autonomy of all of the patients in the above cases. The doctor could have possibly passed on his knowledge had he become healthy enough. The Jehovah’s Witness and the suicide attempt patient both had families that would have suffered emotionally (though not financially) by their loss.
Miller believes that autonomy is actually a fourfold system. He believes that the action must be:
1. A free action – “voluntary and not the result of coercion, duress or undue influence.”
2. Authentic – “an action must be consistent with the person’s attitudes, values, dispositions and life plans.”
3. Effectively deliberate – “a given disposition may not be sufficiently specific to judge that it would motivate a particular action.”
4. Morally reflective – “deliberation using one’s values and plans…as determining what sort of person one will be and in comparison to which one’s actions can be judged as authentic or inauthentic.”
Miller made his opinions on the cases clear in his article. He stated that the “decision to treat the patient [case one]…was clearly a violation of his autonomy.” He discussed the philosophical and theological controversy concerning cases like the second one, but I believe he would have not treated the patient, as was his wish. While he presented both sides of the last two cases in-depth, he didn’t make a concise point about where he stood on this matter. I am lead to believe that he would have treated them anyway as they didn’t seem to be morally reflective or effectively deliberated.
Professor Jonas had three clear rules on human experimentation. They were:
1. Any risk that is taken must be voluntary.
2. Subjects must be recruited from those who are most knowledgeable about the circumstances of research and who are intellectually capable of grasping its purposes and procedures.
3. Experiment must be undertaken for an adequate cause.
Jonas’s stance on the issue correlates to Kant’s maxim to always treat others as an end and not a means only. Unlike Mill [who is interested in the “greatest good” in the “long run”], Jonas would not agree to experiment on someone who didn’t meet the above requirements. If the person would fit Mill’s purpose, he would reap the benefit of their sacrifice.
In his article, “Children in Institutions,” Ramsey addresses the use of humans in experiments, specifically the Willowbrook case. Willowbrook was a home for retarded children in Staten Island, New York. Medical staff culled admission applicants that were waitlisted and bartered space in Willowbrook for parents’ consent to let their children participate in the hepatitis research unit. Meanwhile, the staff was knowingly infecting children throughout the facility with hepatitis so they could study the various effects of doses of the disease against gamma globulin they had provided to control groups.
Ramsey and Jonas hold similar beliefs except that Ramsey takes it one step further. He believes that people [prisoners, patients, parents, etc.] should not be making decisions of this nature while they are under duress; and that the situations presented to both the prisoners in the opening of his article and the distraught parents waitlisted at Willowbrook left them under duress – making their consent null.
As humans we have minds that we can use to grow, learn and develop. What sets us apart from other mammals is that in theory, we have the ability to act according to morals or principles. Aristotle believed that the key to functioning at our best is to live in the “golden mean” which can best be defined as the “right way at the right time, not to either excess.” In this approach, deficiencies are vices along with excesses.
