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PubMed1985

Paternalism modernised.

The practice of paternalism has changed along with developments in medicine, philosophy, law, sociology and psychology. Physicians have learned that a patient's values are a factor in determining what is best for that patient. Modern paternalism continues to be guided by the principle that the physician decides what is best for the patient and pursues that course of action, taking into account the values and interests of the patient. In the autonomy model of the doctor-patient relationship, patient values are decisive. In the paternalistic model, they are but one among several factors the physician must consider in making a medical decision. Although difficult to practise because of limitations in empathising with another person, modern paternalism remains a way to achieve maximum patient benefit.

Beneficence↗
PubMed1986

Medical confidentiality: an intransigent and absolute obligation.

Clinicians' work depends on sincere and complete disclosures from their patients; they honour this candidness by confidentially safeguarding the information received. Breaching confidentiality causes harms that are not commensurable with the possible benefits gained. Limitations or exceptions put on confidentiality would destroy it, for the confider would become suspicious and un-co-operative, the confidant would become untrustworthy and the whole climate of the clinical encounter would suffer irreversible erosion. Excusing breaches of confidence on grounds of superior moral values introduces arbitrariness and ethical unreliability into the medical context. Physicians who breach the agreement of confidentiality are being unfair, thus opening the way for, and becoming vulnerable to, the morally obtuse conduct of others. Confidentiality should not be seen as the cosy but dispensable atmosphere of clinical settings; rather, it constitutes a guarantee of fairness in medical actions. Possible perils that might accrue to society are no greater than those accepted when granting inviolable custody of information to priests, lawyers and bankers. To jeopardize the integrity of confidential medical relationships is too high a price to pay for the hypothetical benefits this might bring to the prevailing social order.

Confidentiality↗
PubMed1986

Patients' wants versus patients' interests.

Should we treat other people according to what they want (their own values), or according to what we take their best interests to be? If they have given us no mandate to decide for them, their values should prevail. This applies not only to allowing but also to assisting them to get what they want. Taking this seriously in medical practice involves a lot of communication between doctor and patient, and a lot of research to establish a typology of patients in respect of their wants. The results would seriously affect doctor-patient relationships and the organisation of general practice and hospital care. It is with this, rather than dramatic 'moral problems', that medical ethics should be chiefly concerned.

Communication↗
PubMed1986

Can paternalism be modernised?

The contention that paternalism can be modernised in such a way as to avoid the usual criticisms is examined and dismissed. The alleged 'modernisation' consists simply in going through the motions of achieving the patient's free consent, while leaving the ultimate decision to the physician. Paternalism in this form is no better than the more old-fashioned variety, since it still takes away from patients the fundamental human right to make decisions about their own fate.

Disclosure↗
PubMed1988

Technical expertise as an ethical form: towards an ethics of distance.

The present article proceeds from the observation that the therapeutic relationship is basically unequal. This inequality essentially concerns the respective situation of the patient and his or her doctor vis-à-vis medical knowledge. A strict professionalism guarantees that this inequality remains factual and without essential value. Yet, if both partners unreflectively allow affectivity excessively to intrude into their relationship, their behaviour may then be inspired by subconscious, rather than rational, motives. In that case, the unverifiable allegations of philanthropy or paternalism may be used to rationalise a kind of 'medical sadism' which attempts to justify the will to humiliate the patient by means of the constraints inherent in medical care. The concept of ethical form is introduced as a non-verbal criterion of ethical reliability. It is mainly a way of training the will through the application of rationally justified rules of behaviour. In this context, it is suggested that an effort to remain constantly within the limits of professionalism represents a method of training for the achievement of some degree of ethical credibility in the therapeutic relationship. In the long term, such abstinence could constitute a sort of catharsis, and thereby help to reveal the non-rational motives in medical behaviour. Contrary to the belief prevailing in modern society, the established limits of medical knowledge are not so broad. The application of these limits would probably be the best method of preventing emotions from interfering undesirably in the therapeutic relationship.

Dehumanization↗
PubMed1989

Obligation and consent.

It is often supposed, as in Professor Kluge's article (1), that one can only acquire an obligation by free consent. This paper argues that although this is true of some types of obligation, including the ones discussed by Professor Kluge, it is by no means true of all. In particular, it is argued, society may legitimately impose obligations on us without our consent, if the obligations are reciprocated, or if it is simply enforcing an already existing moral obligation.

Ethics↗
PubMed1991

Telling the truth.

Are doctors and nurses bound by just the same constraints as everyone else in regard to honesty? What, anyway, does honesty require? Telling no lies? Avoiding intentional deception by whatever means? From a utilitarian standpoint lying would seem to be on the same footing as other forms of intentional deception: yielding the same consequences. But utilitarianism fails to explain the wrongness of lying. Doctors and nurses, like everyone else, have a prima facie duty not to lie--but again like everyone else, they are not duty-bound to avoid intentional deception, lying apart; except where it would involve a breach of trust.

Beneficence↗
PubMed1991

Autonomy, religious values, and refusal of lifesaving medical treatment.

The principal question of this paper is: Why are religious values special in refusal of lifesaving medical treatment? This question is approached through a critical examination of a common kind of refusal of treatment case, one involving a rational adult. The central value cited in defence of honouring such a patient's refusal is autonomy. Once autonomy is isolated from other justificatory factors, however, possible cases can be imagined which cast doubt on the great valuational weight assigned it by strong anti-paternalists. This weight is sufficient, in their estimation, to justify honouring the patient's refusal. There is thus a tension between the strong anti-paternalist's commitment to the sufficiency of autonomy and our intuitions respecting such cases. Attempts can be made to relieve this tension, such as arguing that patients aren't really rational in the circumstances envisaged, or that other values, such as privacy or bodily integrity, if added to autonomy, are sufficient to justify an anti-paternalistic stance. All such attempts fail, however. But what does not fail is the addition of religious freedom, freedom respecting a patient's religious beliefs and values. Why religious freedom reduces the tension is then explained, and the specialness of religious beliefs and values examined.

Attitude to Health↗
PubMed1992

On lying and deceiving.

This article challenges Jennifer Jackson's recent defence of doctors' rights to deceive patients. Jackson maintains there is a general moral difference between lying and intentional deception: while doctors have a prima facie duty not to lie, there is no such obligation to avoid deception. This paper argues 1) that an examination of cases shows that lying and deception are often morally equivalent, and 2) that Jackson's position is premised on a species of moral functionalism that misconstrues the nature of moral obligation. Against Jackson, it is argued that both lying and intentional deception are wrong where they infringe a patient's right to autonomy or his/her right to be treated with dignity. These rights represent 'deontological constraints' on action, defining what we must not do whatever the functional value of the consequences. Medical ethics must recognise such constraints if it is to contribute to the moral integrity of medical practice.

Beneficence↗
PubMed1993

On the morality of deception--does method matter? A reply to David Bakhurst.

Does it signify morally whether a deception is achieved by a lie or some other way? David Bakhurst has challenged my view that it can signify. Here I counter his criticisms--firstly, by clarifying the terminology: What counts as a lie? Secondly, by exploring further what makes lying wrong. Bakhurst maintains that lying is wrong in that it infringes autonomy--and other deceiving stratagems, he says, do so equally. I maintain that lying is wrong in that it endangers trust--and other types of deceiving stratagems do not do so equally. Lying to patients, I contend, is an abuse of their trust. Other forms of their intentional deception need not be so, although, in our autonomy-minded culture, they are likely to be so.

Beneficence↗
PubMed1993

Autonomy and the akratic patient.

I argue that the distinction which is current in much writing on medical ethics between autonomous and non-autonomous patients cannot cope comfortably with weak-willed (incontinent) patients. I describe a case involving a patient who refuses a blood transfusion even though he or she agrees that it would be in his or her best interests. The case is discussed in the light of the treatment of autonomy by B Brody and R Gillon. These writers appear to force us to treat an incontinent patient either as autonomous, just like a rational agent whose decisions are in accordance with his beliefs or as non-autonomous, like comatose patients or children. Though neither is entirely satisfactory I opt for describing such patients as autonomous but point out that in cases like this the principle of respect for autonomy does not give a determinate answer about how the patient ought to be treated.

Adaptation, Psychological↗
PubMed1995

Doctors and nurses once more--an alternative to May.

It is argued that promissory obligation arising from the contract of employment offers a simpler and less contentious explanation and justification of the doctor-nurse relationship at work, than does May's proposal of second-order reasons. The second-order reason position is rejected as the norm for that relationship, and in the exceptional case, where it is admitted, shared employee status is identified as primary validator of a doctor as locus of rational authority. Finally, a brief case is made for a more precise vocabulary to describe the doctor-nurse relationship, as a contribution to more collegial relations.

Contracts↗
PubMed1983

A defence of medical paternalism: maximising patients' autonomy.

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper.

Decision Making↗