The Principle of Beneficence vs Patient Autonomy and Rights

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Special Feature – Medical Ethics Essay

Singapore Med J 2002 Vol 43(3) : 148-151

Deconstructing Paternalism – What Serves the Patient Best?
N H S S Tan (This Essay won the Singapore Medical Association Ethics Essay Award (Non-medical Undergraduate Category) in 2001.)

ABSTRACT On the motion that “medical paternalism serves the patient best”, this essay reviews current arguments on medical paternalism vs. patient autonomy. Citing medico-ethical texts and journals and selected real-life applications like electroconvulsive therapy (ECT) and the advanced medical directive (AMD), the essay argues that medical paternalism cannot serve the patient best insofar as current debates limit themselves to “who” wields the decision-making power. Such
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Paternalists would claim that physicians have a “medical tradition to serve the patient’s well-being”, with the prerogative to preserve life and thus have the patient’s best interests at heart (Mappes and DeGrazia, 1996; p.52).

Singapore Med J 2002 Vol 43(3) : 149

Far from paternalism understood as a dogmatic decision made by the physician, James Childress in his book “Who Shall Decide?” further expounds paternalism into multi-faceted dimensions. Pure paternalism intervenes on account of the welfare of a person, while impure paternalism intervenes because more than one person’s welfare is at stake. Restricted paternalism curbs a patient’s inherent tendencies and extended paternalism encompasses minimising risk in situations through restrictions. Positive paternalism promotes the patient’s good and negative paternalism seeks to prevent an existing harm. Soft paternalism appeals to the patient’s values and hard paternalism applies another’s value over the patient. Direct paternalism benefits the person who has been restricted and indirect paternalism benefits a person other than the one restricted. Whatever the case may be, the guiding principle of modern paternalism,” says Gary Weiss, “remains that the physician decides what is best for the patient and tries to follow that course of action” (1985; p.184). That the physician determines ‘what is best’ is questionable. The medical profession’s back-to-basics
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