J7ournal ofmedical ethics, 1984, 10, 173-178

Paternalism and partial autonomy

Onora O'Neill Department ofPhilosophy, Essex University

Author's abstractA contrast is often drawn between standard adultcapacities for autonomy, which allow informed consent tobe given or withheld, and patients' reduced capacities,which demand paternalistic treatment. But patients maynot be radically different from the rest of us, in that allhuman capacities for autonomous action are limited. Anadequate account ofpaternalism and the role that consentand respect for persons can play in medical and otherpractice has to be developed within an ethical theory thatdoes not impose an idealised picture ofunlimited autonomybut allows for the variable and partial character ofactualhuman autonomy.Autonomous action, understood literally, is self-legislated action. It is the action of agents who canunderstand and choose what they do. When cognitiveor volitional capacities, or both, are lacking orimpaired, autonomous action is reduced or impossible.Autonomy is lacking or incomplete for parts of all lives(infancy, early childhood), for further parts of somelives (unconsciousness, senility, some illness andmental disturbance) and throughout some lives (severeretardation). Since illness often damages autonomy,concern to respect it does not seem a promisingfundamental principle for medical ethics. Medicalconcern would be strangely inadequate if it did notextend to those with incomplete autonomy. Concernfor patients' well-being is generally thought a moreplausible fundamental principle for medical ethics.

But it is also commonly thought implausible to makebeneficence the only fundamental aim of medicalpractice, since it would then be irrelevant to medicaltreatment whether patients possessed standardautonomy, impaired autonomy or no capacity forautonomous action. All patients, from infants to themost autonomous, would be treated in ways judgedlikely to benefit them. Medical practice would bethrough and through paternalistic, and would treatpatients as persons only if beneficence so required.

Recurrent debates about paternalism in medical

Key wordsPaternalism; autonomy; consent; informed consent; respectfor persons; Kantian ethics.

ethics show that the aim of subordinating concern forautonomy to beneficence remains controversial. Thegroup of notions invoked in these debates - autonomy,paternalism, consent, respect for persons, and treatingothers as persons - are quite differently articulated indifferent ethical theories. A consideration of variousways in which they can be articulated casts some lighton issues that lie behind discussions of medicalpaternalism.

1. Paternalism and autonomy in result-orientedethicsMost consequentialist moral reasoning does not takepatients' autonomy as a fundamental constraint onmedical practice. Utilitarian moral reasoning takes theproduction of welfare or well-being (variouslyconstrued) as the criterion of right action. Only whenrespect for patients' autonomy (fortuitously)maximises welfare is it morally required. Paternalismis not morally wrong; but some acts which attempt tomaximise welfare by disregarding autonomy will bewrong if in fact non-paternalistic action (such asshowing respect for others or seeking their consent toaction undertaken) would have maximised welfare.Only some 'ideal' form of consequentialism, whichtook the maintenance of autonomy as an independentvalue, could regard the subordination of autonomy tobeneficence as wrong. In utilitarian ethical thinkingautonomy is of marginal ethical importance, andpaternalism only misplaced when it reflectsmiscalculation of benefits.

This unambiguous picture is easily lost sight ofbecause of an historical accident. A classical and stillhighly influential utilitarian discussion of autonomyand paternalism is John Stuart Mill's On Liberty (1).Mill believed both that each person is the best judge ofhis or her own happiness and that autonomous pursuitof goals is itself a major source of happiness, so hethought happiness could seldom be maximised byaction which thwarted or disregarded others' goals, ortook over securing them. Paternalists, on this view,have benevolent motives but don't achieve beneficentresults. They miscalculate.

Mill's claims are empirically dubious. Probablymany people would be happier under beneficent

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policies even when these reduce the scope forautonomous action. Some find autonomous pursuit ofgoals more a source of frustration and anxiety than ofsatisfaction. In particular, many patients want relieffrom hard decisions and the burden ofautonomy. Evenwhen they don't want decisions made for them theymay be unable to make them, or to make them well.The central place Mill assigns autonomy is somethingof an anomaly in result-oriented ethical thought (2). Itis open to challenge and shows Mill's problem inreconciling liberty with utility rather than any successin showing their coincidence.

2. Paternalism and autonomy in action-oriented ethicsAutonomy can have a more central place only in anentirely different framework of thought. Within amoral theory which centres on action rather than onresults, the preconditions of agency will befundamental. Since autonomy, of some degree, is apresupposition of agency, an action-centred ethic,whether its fundamental moral category is that ofhuman rights, or of principles of obligation or of moralworth, must make the autonomy of agents of basicrather than derivative moral concern. This concernmay be expressed as concern not to use others, but torespect them or 'treat them as persons', or to securetheir consent and avoid all (including paternalistic)coercion.A central difficulty for all such theories is once again

empirical. It is obvious enough that some humanbeings lack cognitive and volitional capacities thatwould warrant thinking of them as autonomous. Butwhere autonomous action is ruled out what can be themoral ground for insisting on respect or support forhuman autonomy (3)? The question is sharply pointedfor medical ethics since patients standardly havereduced cognitive and volitional capacities.

Yet most patients have some capacities for agency.Their impairments undercut some but not allpossibilities for action. Hence agent-centred moraltheories may be relevant to medical ethics, but only ifbased on an accurate view of human autonomy. Thecentral tradition of debate in agent-centred ethics hasnot been helpful here because it has tended to take anabstract and inaccurate view ofhuman autonomy. Thehistory of these discussions is revealing.

Enlightenment political theory and especiallyLocke's writings are classical sources of argumentsagainst paternalism and for respect for humanautonomy. Here the consent of citizens to theirgovernments is held to legitimate government action.In consenting citizens become, in part, the authors ofgovernment action: the notion of the sovereignty of thepeople can be understood as the claim that they haveconsented to, and so authorised, the laws by whichthey are ruled. In obeying such laws they are not meresubjects but retain their autonomy.

This picture invited, and got, a tough focus on the

question 'What constitutes consent?' An early andperennial debate was whether consent has to be express- explicitly declared in speech or writing - or can betacit - merely a matter of going along witharrangements. In a political context the debate iswhether legitimate government must have explicitallegiance, or whether, for example, continuedresidence can legitimate government action. A paralleldebate in medical ethics asks whether legitimatemedical intervention requires explicit consent,recorded by the patient's signing of consent forms, orwhether placing oneself in the hands of the doctorconstitutes consent to whatever the doctor does,provided it accords with the standards of the medicalprofession (4).The underlying picture of human choice and action

invoked by those who advocate the 'informed consent'account of human autonomy is appropriate to acontractual model ofhuman relations. Just as parties tocommercial contracts consent to specific action byothers, and have legal redress when this is notforthcoming, and citizens consent to limitedgovernment action (and may seek redress when this isexceeded), so patients consent to specified medicalprocedures (and have cause for grievance if theirdoctors do otherwise). Those who argue that informedconsent criteria are not appropriate in medical practicesometimes explicitly reject the intrusion of commercialand contractual standards in medical care.The contractual picture ofhuman relations is clearly

particularly questionable in medicine. We may thinkthat citizenship and commerce are areas where we areautonomous decision-makers, enjoying what Millwould have called 'the maturity of our faculties'. Inthese areas, if anywhere, we come close to being fullyrational decision-makers. Various well-knownidealisations of human rationality - 'rational economicman', 'consenting adults', 'cosmopolitan citizens','rational choosers' - may seem tolerableapproximations. But the notion that we could be 'idealrational patients' cannot stand up to a moment'sscrutiny. This suggests that we cannot plausiblyextend the enlightenment model of legitimatingconsent to medical contexts. Where autonomy isstandardly reduced, paternalism must it seems bepermissible; opposition to medical paternalismappears to reflect an abstract and inaccurate view ofhuman consent which is irrelevant in medical contexts.

3. The opacity of consent: a reversal ofperspectiveHowever, the same picture might be seen from quite adifferent perspective. Human autonomy is limited andprecarious in many contexts, and the consent given toothers' actions and projects is standardly selective andincomplete. All consent is consent to some proposedaction or project under certain descriptions. When weconsent to an action or project we often do not consenteven to its logical implications or to its likely results (letalone its actual results), nor to its unavoidable

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corollaries and presuppositions. Put more technically,consenting (like other propositional attitudes) isopaque. When we consent we do not necessarily 'seethrough' to the implications of what we consent to andconsent to these also. When a patient consents to anoperation he or she will often be unaware of furtherimplications or results of that which is consented to.Risks may not be understood and post-operativeexpectations may be vague. But the opacity of patients'consent is not radically different from the opacity of allhuman consenting. Even in the most 'transparent',highly-regulated, contractual arrangements, consentreaches only a certain distance. This is recognisedwhenever contracts are voided because of cognitive orvolitional disability, or because the expectations of the'reasonable man' about the further implications ofsome activity do not hold up. Medical cases may thenbe not so much anomalies, with which consent theorycannot adequately deal, as revealing cases whichhighlight typical limits of human autonomy andconsent (5).

Yet most discussions of consent theory point in theother direction. The limitations of actual humanautonomy aren't taken as constraints on working outthe determinate implications of respect for autonomyin actual contexts, but often as aberrations from ideallyautonomous choosing. The rhetoric of the liberaltradition shows this clearly. Although it is acceptedthat we are discussing the autonomy of 'finite rationalbeings', finitude of all sorts is constantly forgotten infavour of loftier and more abstract perspectives.

4. Actual consent and 'ideal' consentThere are advantages to starting with these idealisedabstractions rather than the messy incompleteness ofhuman autonomy as it is actually exercised. Debates onconsent theory often shift from concern with dubiousconsent actually given by some agent to a proposedactivity or arrangement to concern with consent thatwould hypothetically be given by an ideallyautonomous (rational and free) agent faced with thatproposal. This shift to hypothetical consent allows usto treat the peculiar impairments of autonomy whichaffect us when ill as irrelevant: we can still ask what the(admittedly hypothetical) ideally autonomous patientwould consent to. This line of thought curiously allowsus to combine ostensible concern for human autonomywith paternalistic medical practice. Having reasonedthat some procedure would be consented to by ideallyautonomous patients we may then feel its impositionon actual patients of imperfect autonomy is warranted.But by shifting focus from what has (actually) beenconsented to, to what would (ideally) be consented to,we replace concern for others' autonomy with concernfor the autonomy of hypothetical, idealised agents.This is not a convincing account of what it is not to useothers, but rather to treat them as persons (6).

Ifwe don't replace concern for actual autonomy withconcern for idealised autonomy, we need to saysomething definite about when actual consent is

genuine and significant and when it is either spuriousor misleading, and so unable to legitimise whatever isostensibly consented to. Instead of facing the sharpoutlines of idealised, hypothetical conceptions ofhuman choosing we may have to look at messy actualchoosing. However, we don't need to draw a sharpboundary between genuine, morally significantconsent and spurious, impaired consent which doesnot legitimate. For the whole point of concern forautonomy and hence for genuine consent is that it is notup to the initiator of action to choose what to impose: itis up to those affected to choose whether to accept or toreject proposals that are made. To respect others'autonomy requires that we make consent possible forthem (7), taking account of whatever partial autonomythey may have. Medical practice respects patients'autonomy when it allows patients as they actually are torefuse or accept what is proposed to them. Of course,some impairments prevent refusal or acceptance. Thecomatose and various others have to be treatedpaternalistically. But many patients can understandand refuse or accept what is proposed over aconsiderable range. Given some capacities forautonomous action, whatever can be madecomprehensible to and refusable by patients, can betreated as subject to their consent - or refusal. Thismay require doctors and others to avoid haste andpressure and to counteract the intimidation ofunfamiliar, technically bewildering and socially alienmedical environments. Without such care in impartinginformation and proposing treatment the 'consent'patients give to their treatment will lack theautonomous character which would show that theyhave not been treated paternally but rather as persons.

5. 'Informed consent' and legitimating consentThere is a long-standing temptation, both in medicalethics and beyond, to find ways in which consentprocedures can be formalised and the avoidance ofpaternalism guaranteed and routinised. But if the waysin which human autonomy is limited are highly varied,it is not likely that any set procedures can guaranteethat consent has been given. Early Europeancolonialists who 'negotiated treaties' by which barelyliterate native peoples without knowledge of Europeanmoral and legal traditions 'consented' to sales ofland orcession of sovereignty reveal only that the colonialistshad slight respect for others' autonomy. Medicalpractice which relies on procedures such as routinesigning of 'consent forms ' may meet conditions foravoiding litigation, but does not show concern forhuman autonomy as it actually exists. Such proceduresare particularly disreputable given our knowledge ofthe difficulties even the most autonomous have inassimilating distressing information or makingunfamiliar and hard decisions.

Serious respect for autonomy, in its varied, limitedforms, demands rather that patients' refusal orconsent, at least to fundamental aspects of treatment,be made possible. The onus on practitioners is to see

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that patients, as they actually are, understand whatthey can about the basics of their diagnosis and theproposed treatment, and are secure enough to refusethe treatment or to insist on changes. If the proposal isaccessible and refusable for an actual patient, then (butonly then) can silence or going along with it reasonablybe construed as consent. The notions of seekingconsent and respecting autonomy are brought intodisrepute when the 'consent' obtained does notgenuinely reflect the patient's response to proposedtreatment.

6. Partial autonomy, coercion and deceptionOnce we focus on the limited autonomy of actualpatients it becomes clear that consent to all aspects anddescriptions of proposed treatment is neither possiblenor required. Only the ideally, unrestrictedlyautonomous could offer such consent. In humancontexts, whether medical or political, the most thatwe can ask for is consent to the more fundamentalproposed policies, practices and actions. Patients canno more be asked to consent to every aspect oftreatment than citizens can be asked to consent to everyact of government. Respect for autonomy requires thatconsent be possible to fundamental aspects of actionsand proposals, but allows that consent to trivial andancillary aspects of action and proposals may be absentor impossible.

Treatment undertaken without consent when apatient could have reached his or her own decisions ifapproached with care and respect may fail in manyways. In the most serious cases the action undertakenuses patients as tools or instruments. Here the problemis not just that some partially autonomous patientcouldn't (or didn't) consent, but that the treatmentprecluded consent even for ideally autonomouspatients. Where a medical proposal hingesfundamentally on coercion or deception, not even themost rational and independent can dissent, or consent.Deceivers don't reveal their fundamental proposal oraction; coercers may make their proposal plain enoughbut rob anyone of choice between consent or dissent. Indeception 'consent' is spurious because cognitiveconditions for consent are not met: in coercion'consent' is spurious because volitional conditions forconsent are not met.

However, some non-fundamental aspects oftreatment to which consent has been given may have toinclude elements of deception or coercion. Use ofplacebos or of reassuring but inaccurate accounts ofexpected pain might sometimes be non-fundamentalbut indispensable and so permissible deceptions (8).Restraint of a patient during a painful procedure mightbe a non-fundamental but indispensable and sopermissible coercion. But using patients as unwittingexperimental subjects or concealing fundamentalaspects of their illness or prognosis or treatment fromthem, or imposing medical treatment and ignoring orpreventing its refusal, would always use patients, and

so fail to respect autonomy. At best such imposedtreatment might, if benevolent, constitute imper-missible paternalism; at worst, if non-benevolent,it might constitute assault or torture.

7. Partial autonomy, manipulation andpaternalismUse of patients is an extreme failure to respectautonomy; it precludes the consent even of the ideallyautonomous, let alone of those with cognitive orvolitional impairments. Respect for partial autonomywould also require medical practice to avoid treatmentwhich, though refusable by the ideally autonomous,would not be refusable by a particular patient in his orher present condition. Various forms of manipulationand of questionable paternalism fail to meet theserequirements. Patients are manipulated if they are'made offers they cannot refuse', given their actualcognitive and volitional capacities. For example,patients who think they may be denied further care ordischarged without recourse if they refuse proposedtreatment may be unable to refuse it. To ensure that'consent' is not manipulated available alternatives mayhave to be spelled out and refusal oftreatment shown tobe a genuine option. 'Consent' which is achieved byrelying on misleading or alarmist descriptions ofprognosis or uninformative accounts of treatment andalternatives does not show genuine respect. Onlypatients who are quite unable to understand or decideneed complete paternalist protection. When there is arelationship of unequal power, knowledge ordependence, as so often between patients and doctors,avoiding manipulation and unacceptable paternalismdemands a lot.Avoiding unacceptable paternalism demands similar

care. Manipulators use knowledge of others and theirweaknesses to impose their own goals; paternalists maynot recognise either others' goals, or that they areothers' goals. Patients, like anyone with limitedunderstanding and capacity to choose, may be helpedby advice and information, and may need help toachieve their aims. But if it is not the patients' butothers' aims which determine the limits and goals ofmedical intervention, the intervention (even if neitherdeceptive nor coercive) will be unacceptablypaternalistic. Handicapped patients whose ways of lifeare determined by others may not be deceived orcoerced - but they may be unable to refuse what othersthink appropriate for them. This means that patients'own goals, medical and non-medical, and their plansfor achieving these, are constraints on any medicalpractice which respects patients' autonomy. Sincereturn to health is often central to patients' plans, thisconstraint may require little divergence from thetreatment that paternalistic medical practice wouldselect, except that patients would have to be party tofundamental features of their treatment. But wherepatients' goals differ from doctors' goals - perhaps theyvalue quality of life or avoiding pain or dependencemore than the doctor would - respect for the patient

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requires that these goals not be overridden or replacedby ones the patient does not share, and that thepatient's own part in achieving them not be set aside.

Debates on medical paternalism often assume thatthe goals of medical action can be determinedindependently of patients' goals. But in action-oriented ethical thinking morally required goals are notgiven independently of agents' goals. Paternalism inthis perspective is simply the imposition of others'goals, (perhaps those of doctors, nursing homes orrelatives) on patients. These goals too must be takeninto account if we are to respect the autonomy ofdoctors, nursing homes and relatives. But imposingtheir goals on patients capable of some autonomy doesnot respect patients. The contextually-sensitive,action-oriented framework discussed here does notreinstate a contractual or consumer-sovereigntypicture of medical practice, in which avoiding deceitand coercion is all that respect requires. On thecontrary, it insists that judgements of humanautonomy must be contextual, and that what it takes torespect human autonomy will vary with context. Whenpatients' partial autonomy constrains medical practice,respect for patients may demand action which avoidsnot only deceit and coercion but also manipulation andpaternalism; but where autonomy is absent there is norequirement that it be respected.

8. Respecting limited autonomyMedical paternalism has been considered within threeframeworks. Within a result-oriented framework ofthe standard utilitarian type it is not only permissiblebut required that concern for human autonomy besubordinated to concern for total welfare. Within anaction-oriented framework that relies on an abstract,'idealising' account of human autonomy, medicalpractice is too readily construed as ruling out allpaternalism and permitting only treatment that wouldbe consented to by 'idealised' autonomous agents.Within an action-oriented framework that takesaccount of the partial character ofhuman autonomy wecan sketch patterns of reasoning which drawboundaries in given contexts between permissible andimpermissible forms of paternalism. This accountyields no formula, such as the requirement to avoidcoercion and deception may be thought to yield forabstract approaches. But the inadequacies of thatformula for guiding action when impairment is severespeak in favour of a more accurate and contextual viewof human autonomy.By trying to incorporate concern for actual, partial

capacities for autonomous action into an account ofrespect for patients and medical paternalism we findthat we are left without a single boundary-line betweenacceptable and unacceptable medical practice. Whatwe have are patterns of reasoning which yield differentanswers for different patients and for differentproposals for treatment. One patient can indeed beexpected to come to an informed and autonomous (ifidiosyncratic) decision; another may be too confused to

take in what his options are. A third may be able tounderstand the issues but too dependent or toodistraught to make decisions. Attempts to provideuniform guidelines for treating patients as persons,respecting their autonomy and avoiding unacceptablemedical paternalism are bound to be insensitive to theradical differences of capacity of different patients. Atheory of respect for patients must rely heavily andcrucially on actual medical judgements to assesspatient's current capacities to absorb and act oninformation given in various ways. But it does notfollow that 'professional judgement' or 'currentmedical standards' alone can provide appropriatecriteria for treating patients as persons. For if these donot take the varying ways in which patients canexercise autonomy as constraints on permissibletreatment, they may institutionalise unjustifiablepaternalism. Professional judgement determines whatconstitutes respect for patients only when guided byconcern to communicate effectively what patients canunderstand and to respect the decisions that they canmake.

9. Issues and contextsSections 1, 2 and 3 above discussed some ways in whichtreatment of autonomy, paternalism and respect forpatients are articulated in result-oriented ethics and inaction-oriented approaches which take an abstractview of cognition and volition, and hence ofautonomy.The alternative account proposed in sections 4 to 8 isthat only consideration of the determinate cognitiveand volitional capacities and incapacities of particularpatients at particular times provides a framework forworking out boundaries of permissible medicalpaternalism. If such judgements are contextual, thereis no way to demarcate unacceptable paternalism in theabstract. The following headings only point to contextsin which these issues arise and have to be resolved.Which resolutions are justifiable will depend not onlyon following a certain pattern of reasoning but on thecapacities for autonomous action paticular patientshave at the relevant time.

A. TEMPORARILY IMPAIRED CAPACITY FOR AUTONOMY

If respect for autonomy is morally fundamental,restoring (some) capacities is morally fundamental.Survival is necessary for such restoration; but notsufficient. If patients' autonomy constrains practice,survival can never be foregone in favour of autonomy,but it is an open question whether survival with no orgreatly reduced capacities for autonomy can be apermissible goal. Risky surgery may sometimesreasonably be imposed for the sake of restoringcapacities, even when mere survival would be surerwithout surgery.Temporary loss of autonomy offers grounds for

paternalistic intervention to restore autonomy - butnot for all paternalistic interventions. It might bebetter for an unconscious sportsman if advantage were

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taken of his temporary incapacity to perform somenon-urgent operation or to make some non-medicalintervention in his affairs. But if restoration ofautonomy is likely, an action-oriented ethic offers noground for such paternalism.

B. LONG TERM OR PERMANENT IMPAIRMENT OFAUTONOMY

This is the standard situation of children, and so theoriginal context of paternalism. Those with long anddebilitating illnesses, physical as well as mental, maysuffer very varied impairments of autonomy. Henceconsideration of parental paternalism may illuminatethese cases. While the law has to fix an age to endminority, parents have to adapt their action to aconstantly altering set of capacities for autonomousaction. Choices which cannot be made at one stage canat another; autonomy develops in one area of life andlags in another (9). Unfortunately, medical trajectoriesmay not be towards fuller capacities. Medical and otherdecisions may then have to be to some extent imposed.But there is no general reason to think that those whoare unable to make some decisions are unable to makeany decisions, and even when full return of capacities isunlikely, patients, like children, may gain in autonomywhen an optimistic view is taken of their capacities.

C. PERMANENT LOSS OF AUTONOMY

Here decisions have (eventually) to be made that gobeyond what is needed for restoring (some) autonomy.Sometimes medical staff and relatives may be able tomake some use of a notion of hypothetical consent. Butwhat they are likely to be asking is not 'What would theideally autonomous choose in this situation?', butrather 'What would this patient have chosen in thissituation?' If this can be answered, it may be possible tomaintain elements of respect for the particular patientas he or she was in former times. But usually thisprovides only vague indications for medical or othertreatment, and respect for absent autonomy can be atbest vestigial.

D. LIFELONG INCAPACITY FOR AUTONOMY

For those who never had or will have even slightcapacities for autonomous action the notion of respectis vacuous. There is no answer to the hypotheticalquestion 'What would he or she have chosen if able todo so?' and the hypothetical question 'What would theideally autonomous choose in this situation?' may haveno determinate answer. Here, unavoidably,paternalism must govern medical practice indefinitelyand the main questions that arise concern theappropriate division of authority to make paternalisticdecisions between relatives and medical staff andlegally appointed guardians.

References and notes

(1) Mill J S. On liberty. In: Warnock M, ed. Utilitarianismand on liberty, etc. London: Fontana, 1972.

(2) This has been a recurrent criticism of Mill from StephenJ F, Liberty, equality, fraternity, London: Smith, Elder,1873, to Dworkin G. Paternalism. The monist 1972; 56:64-84 and reprinted in Sartorius R, ed. Paternalism.Minneapolis: University of Minnesota Press, 1983:section IV.

(3) Broader worries mushroom here too: what grounds themoral status of non-autonomous humans in action-oriented ethics? For recent discussion see Haksar V.Liberty, equality, perfectionism. Oxford: Clarendon Press,1979; Clark S. The moral status of animals. Oxford:Clarendon Press, 1977; Dennett D Conditions ofpersonhood. In: Rorty A, ed. The identity of persons.Berkeley and Los Angeles: University of California Press,1976, and reprinted in Dennett D. Brainstorms.Hassocks, Sussex: The Harvester Press, Ltd 1979.

(4) Here US and British practice differ. US legislation anddebates often stress the need to secure informed consentfrom patients (or their guardians). Cf. discussions andbibliography in Veatch R M. Case studies in medical ethics.Cambridge Mass: Harvard University Press, 1977.British law holds that 'what information should bedisclosed, and how and when, is very much a matter ofprofessional judgement', and that 'there is no ground inEnglish law for extending the limited doctrine ofinformed consent outside the field ofproperty rights'. SeeSidaway v Board of Governors of the Bethlem RoyalHospital and the Maudsley Hospital and Others, LawReport, The Times, 1984 Feb 24. However, medicalpaternalism may be more practised in the US than it ispraised by those who write on medical ethics. SeeBuchanan A E Medical paternalism. Philosophy andpublicaffairs 1978; 7: 371-390, and reprinted in Sartorius, seereference (2).

(5) For further comments on the limitations of 'normal'abilities see Wikler D. Paternalism and the mildlyretarded. Reprinted in Sartorius, see reference (2).

(6) A point made long since by Isaiah Berlin in Two conceptsof liberty. Four essays on liberty. Oxford: OUP, 1969.

(7) For the interpretation of Kantian ethics offered here seealso O'Neill 0. Kant after virtue. Inquiry 1984; 26: 387-405; Consistency in action. In: Potter N, Timmons M,eds. New essays in ethical universalizability. Dordrecht,the Netherlands: Reidel publishing company,forthcoming, and Between consenting adults,unpublished.

(8) Bok S. Lying: moral choice in public and private life. NewYork: Harvester Press, Random House, 1978: 234. Bokpoints out that sometimes the use of placebos may bemore than ancillary, (61-68), and also discussesfundamental forms of deception such as hiding from thepatient that the illness is terminal. On the latter point seealso Kubler-Ross E. On death and dying. New York:Macmillan 1969, and the bibliography in Veatch,reference (4).

(9) For discussions of some distinctive features of children'spartial autonomy see Leites E. Locke's liberal theory offatherhood; Slote M A. Obedience and illusions and KatzS N, Schroeder W A, Sidman L. Emancipating ourchildren - coming of legal age in America. In: O'Neill 0,Ruddick W, eds. Having children: philosophical and legalreflections on parenthood. New York: OUP, 1979.

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