Topic:	Paternalism and Health
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Guest:	Agnieszka Jaworska, Assistant Professor of Philosophy, Stanford University
What is it?	Paternalism and Health: Some diseases such as Alzheimer's inhibit our abilities to make decisions and lessen our quality of life. In cases like these, we often think that others are justified in stepping in and making decisions for that person. But what about the case where the person in question is relatively healthy but suffers, perhaps, from minor depression, or an anxiety disorder? When (if ever) is it OK to step in and take charge of someone else's life or body?

About the Guest

Agnieszka Jaworska's primary area of research lies at the intersection of ethical theory, medical ethics, and moral psychology. Her current project, entitled “Ethical Dilemmas at the Margins of Agency,” concerns the ethics of treatment of individuals whose status as persons is thought to be compromised or uncertain, such as Alzheimer's patients, addicts, psychopaths, and small children. It is part of a larger project on the nature of value and the moral psychology of valuing.  She received training at the Department of Clinical Bioethics at the National Institute of Health.  Professor Jaworska spent the 2003-04 academic year as a fellow at the prestigious Center for Human Values at Princeton University.

Paternalism occurs when someone acts to make a decision for another or acts to prevent another from carrying out a decision on the premise that such an action is for that person's own good. In healthcare, paternalistic measures are often used when dealing with those who are mentally unstable, who have a disease such as Alzheimer's, or are otherwise incapacitated from making fully rational choices for themselves. When acting paternalistically toward someone, there is always tension between the need to respect that person's autonomy and the moral obligation to help others. However, how much autonomy do those we treat paternalistically really have? John and Ken introduce the topic of paternalism by discussing the way in which we treat children. Ken asks the question: do we treat children paternalistically because they are not rational? John argues that we do and in fact should act paternalistically toward children, making decisions for them in accordance with what we think is best—with how we think their future adult selves will approve. We can divide children into two groups: elementary school children and teenagers. True children or very young people have no ability to acquire the information, reasoning skills, and evaluative capacities to make autonomous decisions. Teenagers, on the other hand, have the rational capacity to make decisions and have desires that they are capable of arguing for vigorously. Still, adults can be justified in acting paternalistically toward teenagers who are in the process of figuring out how best to use their newly- acquired autonomy. Ken makes the point that, just as we decide what's best for children based on the perceived wishes of their future selves, it might be the case that we should decide what's best for a patient with Alzheimer's based on the wishes of her past selves. However John counters that, although this conception would produce symmetry in our thinking about the issue, there is a difference between the past and the future. For an Alzheimer's patient who has lost her memory and with it her reasoning capacity, there is no future self who will understand or make connections with who they were in the past. In such circumstances, why shouldn't the present desires of the person be respected?

Guest Agnieszka Jaworska claims there needs to be a balanced framework for evaluating and making decisions that reflect both the interests and values of the fully autonomous person and the interests and values of the patient with Alzheimer's. Alzheimer's is a disease that moves in stages, gradually diminishing a person's autonomy. Our ability to have convictions and a moral sense is what it means to have autonomy. So, consider a person who still has some elements of autonomy but doesn't have full autonomy because of Alzheimer's disease. The fact that they have some autonomy doesn't mean we shouldn't make decisions for them: it means that we shouldn't make decisions for them that are based exclusively on their prior values and convictions. We should respect their wishes to the extent that they are still autonomous and make decisions that reflect the patients' current values as well.

In further discussion about autonomy, John quotes John Stuart Mill from his book On Liberty. Mill claims that no one should be allowed to overpower a person's will regardless of whether or not others feel doing so would be for the person's own good, be a wise choice, or be morally right. The only exception to this rule is when the action a person wishes to undertake will harm others. John is concerned both with whether we can accept this claim and what it' implications are for Alzheimer's patients who are in the most early stages of the disease. Jaworska mainly addresses his second concern. For ordinary adults, the current understanding is that it is wrong to interfere with a person's will. However, in the case of Alzheimer's patients, it is unclear whether they have fully-formed rational capacities or not. According to Jaworska, a will has several components. The first is the ability to conceptualize the good—i.e. a sense of right and wrong when choosing to act on desires. Then, there is the ability to criticize or critique this conception, the ability to make a decision based on these considerations, and the ability to follow through with a decision. A person can have part of this capacity or will while lacking other necessary components. For example, a person could have the ability to form convictions while lacking the ability to critically evaluate and practically carry out her decisions. People with early-stage Alzheimer's, Jaworska contends, experience these types of limits in their decision-making capacity which is why they are not fully autonomous and, consequently, do not fall in the general category of individuals to which Mill's statement is meant to apply.

• Amy Standen the Roving Philosophical Reporter (Seek to: 00:04:27): Eight years ago, Doris' husband Eddie was diagnosed with Alzheimer's disease. Just a little while before that, Eddie and Doris were driving from New Hampshire to California when, for the first time ever, Eddie let Doris drive. Doris explains how, at first, the signs of Alzheimer's arose almost imperceptibly in particular changes that she noticed but that were so small that no one else could tell the difference. Then, as the years went by after his diagnosis, Eddie's condition grew significantly worse.

• Philosophy Talk Goes to the Movies (Seek To 00:47:51): In the movie Shrek 2, both Fiona and Shrek are given the opportunity to change their appearance, transforming themselves into good-looking human beings. Philosophically speaking, what should they have decided to do?

Additional Resources

• Information on the case of Dax Cowart, whose request to die after being critically burned in an accident was overruled by physicians on the grounds of incompetency. Physicians went ahead with treatment, even after it was clear that Cowart possessed a great deal of sound rational capacity..

• An introduction to paternalism, its benefits, and its controvercial implications.

• Articles from JSTOR (note: subscription required to view online.)
  • Allen Buchanan .  "Medical Paternalism."  Philosophy and Public Affairs, Vol. 7, No. 4. (Summer, 1978), pp. 370-390.

   

  • Bernard Gert; Charles M. Culver.  "The Justification of Paternalism." (in Discussion)  Ethics, Vol. 89, No. 2. (Jan., 1979), pp. 199-210.

   

  • Jennifer Radden .  "Second Thoughts: Revoking Decisions Over One's Own Future."  Philosophy and Phenomenological Research, Vol. 54, No. 4. (Dec., 1994), pp. 787-801.

• Other articles and texts:
  • Aharon Aviram.  "The Paternalistic Attitude Toward Children."  Educational Theory (Spring 1991) pp. 199-211.

   

  • Joseph P. DeMarch.  "Competence and Paternalism."  Bioethics, Vol. 16, No. 3 (June 2002) pp. 231-245.

   

  • Samuel Gorovitz.  "Ethical Dilemmas in Medicine: Who Should Decide?"  National Forum: Phi Kappa Phi Journal, Vol. 58 (Spring 1978) pp. 3-8.

   

  • Harry Lesser.  "Consent, Competency and ECT: A Philosopher's Comment."  Journal of Medical Ethics, Vol. 9 (Spring 1983) pp. 144-145.

   

  • Haley Richmond.  "Paternalism and Consent: Some Educational Problems."  Journal of Philosophy of Education.  Vol. 32, No. 2 (July 1998) pp. 239-251.

   

  • Richard Sherlock.  "Consent, Competency and ECT: Some Critical Suggestions."  Journal of Medical Ethics, Vol. 9 (Spring 1983) pp. 141-143.

   

  • Ferdinand Shoeman.  "Parental Discretion and Children's Rights: Background and Impliations for Medical Decision-Making."  Journal of Medicine and Philosophy, Vol. 10 (February 1985) pp. 45-62.

   

  • John H. Sorenson, Garrett E. Bergman.  "Delineating Paternalism in Pediatric Care."  Theoretical Medicine, Vol. 5 (February 1985) pp. 93-104.

   

  • Caroline Whitbeck. "Why the Attention to Paternalism in Medical Ethics?" Journal of Health Politics, Policy and Law, Vol. 10, No. 2, (1985) pp. 181-187.