Bioethics: Human Life Issues
Medical Paternalism and its Refutation
Medical Paternalism and its Refutation
Q1a. Describe the argument Alan Goldman presents in “The Refutation of Medical Paternalism”.
In "The Refutation of Medical Paternalism" Alan Goldman addresses the question of whether doctors have such authority to make decisions for patients that they would never have as nonprofessionals. First, he delineates the arguments of those who advocate medical paternalism and then provides his refutation. Paternalism is defined as "the overriding or restricting of rights or freedoms of individuals for their own good" CITATION Gol98 \l 1033 (Goldman, 1998). Alan identifies truth-telling and informed consent to treatment as a fundamental issue. He regards the question of making decisions and having access to information of primary interest to the patient himself.
He argues that rights allow people to have control over their own lives and futures. Decisions crucial to a person should be left to be made by the person himself because people are the best judges of their own interests. Their interests are best known to them because their personal values and preferences are known only to them. When others make decisions for someone, they tend to incorporate their own preferences and values. This may hinder the satisfaction for the individual.
Goldman rejects medical paternalism on the ground that it is based on the faulty argument that health and prolonged life are the foremost priorities of the patient. This assumption is faulty. Otherwise, the government should allocate the entire budget to the health sector. Moreover, people engage in taking risks in their lives every now and then. A person might not ascribe as much value to life that is marred by a chronic disease as he would in normal circumstances.
Self-determination carries an independent value, more so in regards to crucial decisions. In medical related issues, the decisions may involve the alternatives of life and death and affect a person's planning to complete major projects. The decisions may have bearing on bodily integrity as well. Everyone wishes to make their own informed decisions and the fulfillment of this wish is extremely important. Overall harm and resentment are far greater when caused by a wrong, though well-meaning, the decision of another person than when caused by one's own decision.
The right of self-determination encompasses the right to be told the truth about one’s health and medical condition. It also includes the right to decide whether or to take treatment on the basis of information provided by the doctor regarding the risks and alternatives.
The duty not to harm should override the duty to provide benefits. Even if the potential benefit of treatment is greater than the risks involved, it cannot be used without the consent of the patient. Therefore, lying to patients about the severity of their illness to avoid depression or distress and subjecting patients to treatment without informing them of the potential risks, no matter how small the risk may be, are unjustified and oppose the principle of self-determination. Lying in such cases is wrong because the person is robbed of his or her right to decide future courses. A person who is not informed fully might not complete some projects which he would have completed otherwise. This makes lying akin to coercing a person to do something he would not otherwise do.
Q1b. Would Goldman approve of Dr. C.’s refusal to disclose full information to Marcia W.? Explain.
Goldman would certainly not approve of Dr. C.’s refusal to disclose full information to Marcia W. She has already shown a great interest in making an informed decision about her further treatment. Goldman would defend her right to self-determination. Dr. C. himself chooses a course for Marcia at the cost of her right to make crucial decisions for herself. So first of all Dr. C has violated her right to such crucial information that has a direct bearing on her future and her decision whether or not to take the treatment.
Goldman would defend her right to know the truth about the risks involved in chemotherapy. Since there is every possibility that she would be among that 10 % who contract leukemia 20 years after chemotherapy, she would be the one, not the doctor, suffering from highly resistant leukemia. Therefore, she has every right to know about a risk that can possibly have far-reaching consequences for her health in the future.
Since the risk involved is grave, even if its possibility is only 10%, it is crucial for Marcia W.’s decision making. Her earlier shown desire that she should be provided with the information required for making an informed decision makes it all the more important that she should be told about the 10% risk. Goldman would argue that hiding this information from her would be akin to coercing her to take the treatment without her will.
She might not be among the 10 percent who contract a form of leukemia that is highly resistant to treatment, but there is a chance, no matter how little, that she might be among the 10 percent. In that case, she would be suffering from a disease that is highly resistant to treatment solely because of someone else's decision.
Goldman would argue that in case she takes up the treatment based on incomplete information and then contracts the said leukemia, the psychological harm to her and the resultant resentment towards the doctor would be far greater than the harm and resented caused by her own decision. Therefore she should be informed about the risks involved in the treatment before subjecting her to it.
Goldman would also highlight that if she is informed about the risk of contracting leukemia after 20 years of chemotherapy, she might plan and complete some important projects in her life beforehand. She may be well prepared for taking the pain and even for death. But without knowing about the possibility of contracting untreatable leukemia, she might miss upon many experiences and might take a course of life she would have never taken had she known about the risk.
Although 50% of patients die within two years of chemotherapy, the prospects of long term lives do exist for the remaining 50%. Likewise, although 10% of that 50 % might get leukemia, the remaining 90% have good prospects. Marcia W. would not have any difficulty in knowing about this positive aspect of the treatment. Therefore, the doctor is wrong in his assumption that divulging the information about risks will rob her of possibility to long term life.
Moreover, the refusal to disclose the information about the risk cannot be justified on the ground that 10% is a small figure. She could still be among that 10 % and if she turns out to be among them, then her life would be totally different from what she would envision in case she knew about the risk. Therefore Goldman would argue that knowing the possibility of leukemia, she could plan and execute some really important projects in her life beforehand. Whether she gets leukemia or not, she could be better prepared for it in the preceding twenty years.
Q1c. Do you think that Dr. C.’s refusal is justified? Why or why not?
I think Dr. C.’s refusal is unjustified. I am aware that it is practically impossible to provide the patient with all the truth because they do not have adequate information related to medical sciences. Therefore they cannot process, understand and digest all the technical details CITATION Mac79 \l 1033 (Lipkin, 1979). However, such information which the patient has the ability to understand and on the basis of which the patient can consequently make rational decisions should be provided to the patient. Providing such information becomes all the more important when the patient has already requested for it in order to make an informed decision about her treatment.
The doctor's assumption that divulging the information about the risk of leukemia in 10% percent of patients will result in a wrong decision on her part is misplaced. It is misplaced because the patient can herself understand the pros and cons of treatment once she is provided with all the information. She already knows that 50% of all patients die within two years of chemotherapy. But she also knows about the better prospects of the chemotherapy i.e. possibility of living a long term life which does exist in the remaining 50% of patients taking chemotherapy. Similarly, she can easily understand that although 10% of surviving 50% might contract leukemia, the prospects for 90% are great. Therefore, she would most probably agree to take the treatment. Since she is already 40 years old and after 20 years she will be 60. Knowing this that chemotherapy can give her these 20 important years, she may become willing to take the therapy and live with untreatable leukemia. Hence the doctor’s assumption that she would not take the treatment is wrong and misplaced.
Whether the 10% risk is higher or lower, knowing it before undertaking the chemotherapy is still very important. As the leukemia is contracted after 20 years, Marcia W can prepare well for the risk beforehand. If she knows about the possible risks, she may plan and execute some crucial projects in her life. In addition, she will be psychologically in a better position to face the situation.
There is no doubt that the harm and frustration would be far greater if she contracts the disease without knowing about it. She might feel stripped of her right to make her own informed decision and therefore her hatred directed towards the doctor will be intense. Therefore, her right to determine a course of action for herself is of paramount importance.
The question of having unnecessary depression and anxiety if she is told about the 10% risk does not arise in the case of Marcia. She is already 40 years old. Undergoing chemotherapy will give her 20 long years of life if she is among the lucky 50%. So even if she contracts leukemia after 20 years of chemotherapy, she would have lived those 20 years pretty well. Keeping in view the prospects of healthy 20 years, she will go for therapy and rationally so. We know that not taking therapy in myeloma is a painful experience. Hence the 10% risk will most probably not deter her or make her depressed.
BIBLIOGRAPHY Goldman, A. (1998). The Refutation of Medical Paternalism. In A. Goldman, Ethical Issues in Modern Medicine (pp. 59-67). Mountain View, California: Mayfield Publishing Company.
Lipkin, M. (1979). On Telling Patients the Truth.
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