Hard Paternalism

Is hard paternalism in medicine ever justified?   In a recent NYT op-ed titled “When Doctors Need to Lie,” cardiologist and author Sandeep Jauhar provides a thought-provoking perspective on this question.

Dr. Jauhar begins with a description of a case in which the father of a 22-year-old patient requested that Jauhar temporarily lie and tell the patient that was going to be fine, even thought he was suffering from severe heart failure.  Jauhar agreed on grounds that the patient was not yet psychologically ready to hear the news and that withholding the information was therefore justified by the central principle that “physicians must do no harm.”

This example of temporary lying provides an avenue into a general discussion of the role of paternalism in medicine, which Jauhar argues should not be wholly displaced by respect for patient autonomy.   He argues that “when a doctor believes that a paternalistic approach is justified, he should aim to keep it as ‘soft’ as possible,” but that “there may be a place in medicine for hard paternalism, too.”

In support of hard paternalism, Jauhar describes a case in which one of his patients was bleeding into his lungs and was going to die without a breathing tube.   Jauhar knew that the patient had previously told other doctors that he never wanted to be intubated, but he did not know the quality of their discussion and could not find out because the patient was nearly unconscious.   So he intubated the patient, thereby saving his life.  And in the end, the patient thanked him.

But does this story actually offer support for hard paternalism?    It seems to me that the intuitively compelling justification for the decision to intubate in this case turns on the fact that (a) Jauhar did not know the quality of the discussion that led to the patient’s statement that he never wanted to be intubated, and (b) the patient was subsequently thankful.  This suggests, however, that we do not really see this as a case of hard paternalism.  Rather, we see it as a case in which a doctor thought that his patient would not have stated an opposition to a procedure if he had been properly informed, and the patient’s subsequent thanks confirmed that he was right.

Perhaps the decision to only respect a patient’s preference if it is sufficiently informed—or to think that a patient’s future informed preference can justify disregarding his preference at the time of the procedure—is itself a form of paternalism.  But it is not the hard paternalism that Jauhar sets out to defend.

What is needed to support hard paternalism is a compelling case in which a patient’s informed choice is overridden based paternalistic concerns that are not subsequently validated by the patient.  Or, to return to the opening theme of the op-ed, a compelling case in which a doctor lies to a patient not temporarily but rather permanently.

0 thoughts to “Hard Paternalism”

  1. I do not see justification for “hard” paternalism. Even if, as the author mentions, we were to discover one case in which hard paternalism seemed to be justified, that would be ONE case, not nearly a sufficient sample size to indicate overhaul of one of the founding principles of medical ethics. Furthermore, I am not certain that respect for patient autonomy can or should be overly influenced by empirical data. Not every normative principle can be adequately evaluated based on empirical studies. We respect patient autonomy because it is the right thing to do, because we believe that at the level of fundamental human rights, everyone has the right to bodily integrity; the right to control what happens to his or her body. If we had a population survey which showed 90% of the US suddenly stopped believing in this human right, would we be correct to stop teaching its existence? We can go to a number of countries around the world right now which do not believe in the human rights we champion, but that does not deter our fundamental belief that these rights do in fact exist. Just because you find a group of people who do not believe in respecting patient autonomy, does not mean that patient autonomy should no longer be considered the minimum of basic human dignity which we can bestow on patients. From my perspective, the entire premise of this article is flawed.

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