The Moral Issue of Paternalism and Truth Telling

• In ancient China, a Confucianist thinker Meng Tze or Mencius stated that there are four beginnings that differentiate man from beasts:

1. The feeling of helpfulness and commiseration- which is the human-heartedness2. The feeling of shame and dislike- which is the beginning of righteousness3. The feeling of modesty and yielding- which is the beginning of propriety4. The sense of right and wrong- which is the beginning of wisdom• Paternalism

Definition of Paternalism:• from the Latin pater ‘father’ or paternus ‘fatherly’ paternalism means the act of being fatherly

to someone, as if the latter were one’s own offspring. • acting like a father to a person for the latter’s own good and interest

It is argued that a paternalistic act is believed and intended to protect or advance the interest of its recipient, although such an act may go against the latter’s own immediate desires or may limit his freedom of choice. Is a paternalistic act, therefore, morally legitimate? Will it not circumvent and undermine the recipient’s right of self determination or autonomy? Types that define the general idea of Paternalism:1.With regard to the recipients welfare, paternalism may be either pure or impure.

-Pure paternalism justifies intervention into a person’s life for the sole welfare of that person.-Impure paternalism justifies interference with another person not only for that person’s

welfare but also for the welfare for another. 2. With regard to the recipient’s defect and safety, paternalism may be either restricted or extended.

-Restricted paternalism supports intervention which overrides an individual’s action because of some defect or weakness in that individual.

-Extended paternalism, is one in which an individual is restrained from doing something because it is too risky or dangerous.3. With regard to the promotion and prevention of harm, paternalism may be either positive or negative. 4. With regard to the patient’s sense of values, paternalism may be either soft or hard.

-Soft paternalistic act, the patient values are used to justify the intervention with his possible action or decision while hard paternalism , the patient’s values are not the ones used to justify a paternalistic act. 5. With regard to the recipient of the benefit, paternalism may be direct or indirect.

-direct paternalism, the individual who should receive the supposed benefit is the one whose values are overridden or disregard for his own good.

-indirect paternalism, a particular individual will be benefited, if one person is restrained from doing something.In the Medical Context:

1. Personal paternalism – an individual decides on the basis of one’s best knowledge of what is good for another person.

2. State paternalism – refers to the control exerted by the legislature, an agency, or other government bodies over particular kinds of practices and procedures in medicine.

Justifications for Personal Paternalism:1.The recipient of the paternalistic act is sick and consults the physician seeking medical expertise and assistance.2. The recipient of the paternalistic act has some incapacity which prevents him/her from making a decision.3. To the best of one’s knowledge and training, there is the probability of harm unless a paternal decision is made; here one needs to determine if all harms are equal.

4. The probable benefit of paternal intervention outweighs the probable risk of harm from noninterference.5. The physician has an obligation to act in the best interest of the patient.6.The patient, upon consulting the physician, voluntarily transfers part of his/her autonomy to the latter based on faith in the physician. Justifications For State Paternalism:

1. To improve the good quality of medical education.2. To upgrade a high standard of medical care3. To control drug addiction, other drug abuses, or the spread of AIDS and other sex-related

diseases.Application of Ethical Theories:

1. Natural law ethics-endorses both kinds of paternalism: personal and state paternalism.-Individuals possess inherent worth and have the freedom to make moral decisions by and for

themselves. Individuals, however, may not have the pertinent information, the sufficient knowledge, and the capacities needed to determine what is really in their best interest.

-Sometimes, individuals are just moved by momentary passions and unforeseen circumstances

to make haphazard decisions. It is for such reasons that the state is organized to bring about such natural benefits as health, medical practices, and laws that promote the common good; hence state paternalism is morally right.2. Kant's ethics

-considering Kant’s concept of a person as a rational and autonomous agent, it seems that he might be against paternalism. A paternalistic act may be taken as an interference with an individual’s autonomy and self-regulating will.3. Rawls’s ethics

-Rawl’s theory of social and political morality is compatible with state paternalism. Society might decide to institute a set of medical practices and policies that would promote common interests and general welfare.

-each person has a moral right to be treated as an autonomous agent who has to make decisions by and for oneself. 4. Utilitarianism

-endorses paternalism insofar as state laws and policies justified by the principle of utility. Restricted individual liberty may promote the greatest benefits for the greatest number.

-individual freedom has no absolute value, it ca be restrained or restricted for the sake of the many.

• Truth Telling Does a patient have the right to know the truth about himself/herself?

• Does a physician have the obligation to tell the truth to a patient? Two approaches to the truth telling issue:

1. The Person-centered-importance to the patient as a person-considers a person as a person with a problem, but not as a problem himself/herself.-one has the right to know the nature of one’s disease and the physician is morally obligated to

respect that right.2. The Problem-centered

-consider the patient’s problem, illness, or condition-the physician may not tell the truth when it is in the best interest of the patient; , after all the

physician is fallible and makes mistakes. Thus, if only for the best interest of the patient’s failing or worsening condition, the physician may withhold the truth from the patient.

Joseph Fletcher compares the twofold approach to truth-telling with what Martin Buber define as types of two relationship:1.The I-it

-describes a person’s relationship with things, objects, or “its”- man-object; subject-object relationship-determined by our attitude to what is other than ourselves

2. The “I-thou”-delineates our relationship with other persons, like ourselves, other subjects, I’s, thou’s or you’s-subject-subject, person-person relationships-the other person is a fellow human being, a thou or someone with integrity and moral quality

of his/her own, I cannot manipulate or use him/her without degrading or dehumanizing him/her at the same time. For persons, like myself, are not things or objects which are usable and manipulate by other persons In the Medical Context:

• the physician-patient relationship exemplifies an “I-thou” or person-person relationship-a moral experience because persons can respond; they are responsible; unlike things, they can

say ‘yes’ or ‘no’ in response to any course of action: the right to self-determination, the right to be themselves, to choose to be a ‘you’ rather an it.In Fletcher’s view:

• A patient simply becomes an object of medical treatment, who submits himself to a physician, without any knowledge of his condition and its prognosis, the patient has ceased to be a ‘thou’ and has become an ‘it’. He is used and manipulated as if he were a thing or object; he is no longer accredited as a person, and hence is deprived of personal responsibility and moral status.

Justifications for Truth-telling:1. It is argued that are human and moral quality as persons is taken away from us if we were denied whatever knowledge is available about our condition as patient, as the case may be2. As patients, we have entrusted to the physician any knowledge he has about ourselves, so the facts are ours and not his—hence to deny them to us is to steal from us. 3. The highest conception of the physician-patient relationship is a personalistic one which is based on mutual confidence and respect for each other’s rights.4. To deny a patient pertinent knowledge about himself, especially in a life-and-death situation, is to deprive him the ample time to prepare for his own death or to carry out responsibilities that are based solely on his decisions or actions.Confidentiality

-from the Latin confidere ‘to trust’-medical or professional secrecy in which certain information is committed to a physician in an

official capacity for the sake of medical assistance-this is in conjunction with one provision of the Hippocratic Oath: “whatever I see or hear,

professionally or privately, which ought not to be divulged, I will keep secret and tell no one” • The practical function of confidentiality in a physician-patient relationship underscores the

confidence and trust that the patient has for the physician. With this feeling of confidence, the patient is not reluctant but cooperative in giving the personal information to the physician.

• The moral issue of confidentiality arises if and when there is a conflict between individual interest and the interest of society. The physician is placed in the middle of a conflict between the interest of the individual and the interest of the society.

• Confidentially is not absolute. Under certain conditions, it is better to violate it than to preserve it. Confidentiality can be violated if it is necessary to produce conditions which will bring about happiness and well-being.

Four conditions may be cited to justify the violation of Confidentiality:1. When keeping the secret would be detrimental to the common good.2. When the subject of the secret intends to inflict grave injury upon an innocent third party.

3. When it is necessary for the subject of the secret to avert grave injury.4. When it is necessary for the one keeping the secret to avoid grave injury.

Application of Ethical Theories:1. Natural Law ethics

-maintains that each individual has an inherent worth, and so is entitled to know the truth about himself or herself.

-recognizes the superior knowledge of the physician, who may perceive the best interest of the patient better than the patient himself.

-considers the necessity of withholding information from the patient of certain occasions for the patient’s well-being.

-perceives with the relationship between physician and patient is one of trust and confidence. A physician therefore has a duty not to betray the confidence of his/her patient. Such a relationship, however, is not sacred and such a duty not absolute. If the physician’s perception a greater wrong or evil will be committed by not divulging what the patient has confided, then by all means the physician has a duty to break that confidence.2. Ross's ethics

-between two conflicting prima facie duties—the physician’s duty to the patient and to the state– the latter appears to be more stringent than the former. Hence, it becomes the physician’s duty to preserve the interest of the society or to protect the common good. The same holds true for truth telling. If the physician honestly believes that withholding the information would be in the best interest and well-being of a particular patient, then it becomes the physician’s actual duty to withhold the information.3. Kantian ethics

-precepts regard truth telling and confidentiality as absolute. -In the physician-patient relationship, the former is under obligation to preserve confidentiality

because keeping promises is an absolute duty.-In the matter of truth telling, the categorical imperative rules out lying; a patient is a person

who is entitled to receive information about his/her condition, no matter how painful it may be.4. Situationism

-one should consider the circumstances prevailing in particular situation. Whatever these circumstances are, however, one should make one’s decision in the name of agapeic love or concern for the welfare of the patient. Would it do the patient more good than harm? Then, the expediency of the given situation should be one’s guide in making a decision.