The Principle of Beneficence vs Patient Autonomy and Rights

Authors Note: This paper is being submitted on the 18th of March 2013 for the winter semester of Medical Law and Ethics section 05.

Katz states, “the conviction that physicians should decide what is best for their patients, and, therefore, that the authority and power to do so should remain bested in them, continued to have deep hold on the practices of the medical profession “(214).

In his article “Whose Body Is It, Anyway?”—appearing in the New Yorker in October 1994—Dr. Atul Gawande highlights the complexities of the doctor-patient relationship vis-à-vis patient autonomy and decision-making. Dr. Gawande explains that a respect for patient autonomy (i.e., allowing patients to choose between courses of treatment, therefore directly influencing their health outcome) is the “new normal” for medical practitioners. However, Gawande also contends that there are times when patients are better served by a voluntary relinquishment of that autonomy.

The concept of paternalism involves the notion that one person, generally a person in a position of authority, has the right to intervene and override the autonomy of another person. In terms of historical context, medicine is one area in which paternalism has occurred frequently. Throughout the ages, physicians and doctors have been placed in a position of authority in which they acted upon the bodies of their patients without those patients’ full knowledge or understanding. However, there has been a distinct shift in modern times regarding paternalism. With the publication of The Silent World of Doctor and Patient, Jay Katz advocated for a new attention to be given to the autonomous control of the patient. Katz noted that historically speaking,

The doctor felt he was operating with beneficence, but was in effect, violating the patient’s autonomy by not taking into account the patient’s desires as well as not fully explaining the treatment. As a young, inexperienced nurse, I failed my patient because I did not advocate for his desires. The patient subsequently died alone in a hospital bed, away from his wife. I learned by this ethical failure to always be a patient advocate, and it has defined my clinical practice for the last twenty years. This is why autonomy is so important to

The American Medical Association (AMA) published a Code of Ethics for Physicians that includes a list of certain principles physicians should follow in order to be good physicians, practicing in an ethical fashion. This list, which was first adopted in June of 1957 and revised as recently as June of 2001, demonstrates some principles that are not universally accepted to be critical to the ethical practice of a physician. In particular, all physicians do not completely believe the claim that “A physician shall support access to medical care for all people” (Principles of Medical Ethics). Theorist, H. Tristam Engelhardt believes that the lack of access to care for some may be unfortunate, but it is not unfair and that this access does not need to be mandated, nor does believing it should be make you an ethical physician. In fact, Engelhardt supremely believes that by providing access of care to all, you will hurt certain patients that already have access to care, negating your function as a physician practicing beneficence. Engelhardt would retract this statement from the Principles of Ethics. However, this belief of and drive to implement access of care to all is critical to one’s job as a physician and it goes against core values of physicians to claim otherwise. Theorists such as Tom Beauchamp and Norman Daniels would agree that the universal access to health care is a critical component of the values physicians hold.

17. Pellegrino argues for a three-tiered system of obligations incumbent upon physicians. They are in ascending order of ethical sensitivity.

Goldman’s critique of medical paternalism demonstrates the right for patient autonomy and decision to choose a treatment best suited to their needs and interests. Initially, physicians would not announce any form of cancer to their patients, as it was believed to result in physiological distress. Luckily, medical paternalism continues to be rejected in medical situations; the topics of outcomes research, scientific evidence, and court decisions help correct patient decisions on the best treatment.

To argue the first premise, he appeals to common knowledge that doctors hold their occupations because they are more knowledgeable in a medical context on the options for improving health and longevity. With this in mind, he then establishes that individuals who consult physicians do so in order to prolong their life and improve their well-being. By establishing these foundational premises for paternalism in a medical context, Goldman can now argue that given a patient that is determined to be acting out of line with his true values and his actions might result in harm that is severe, certain, and irreversible, it is the physician’s professional to override the patients’ immediate rights in order to preserve that patients’ more long-term desires. But how can the physician determine whether the patient is acting in line with his true values in the case of withholding medical information from the patient?

Subsequently, paternalism is ethically controversial in medicine because it can potentially violate patient autonomy. Patient autonomy is important to respect and violation of this can have severe consequences. A patient that is mentally competent has the opportunity to make their own medical decisions. Paternalism is also ethically controversial because of the ethic of beneficence. This also leads to duty-ethics because physicians have the duty to use their best judgement is assisting their patients.

Physicians, in their daily practices will tell you, not all patients when being examined will comply with the doctor’s wishes. Likewise, Law Enforcement. Police, can tell you also not all calls went as smooth as it should most of the times. Nearly all doctors will agree that children, and the mentally incompetent, are the most difficult patients to deal with. Because of incompetence, these patients are not able to make decisions for themselves. Doctors are presumably likeable people, because, when you are sick, they make you healthier, although for others, doctors can be villains. Patients whose doctor’s force treatment on them perceive this as a violation of their rights. The use of force should be mandatory when patient health becomes life threatening to themselves and the public at large.

Autonomy was not always the governing ideal in the medical world, in fact, the act of restricting responsibility and decision making capabilities (paternalism) had control. The paternalistic philosophy dominated physician-patient care until the mid 1960s, when Doctor Henry Beecher published the article “Ethics and

Doctors are not as a matter of course anticipated that would experience this expansive meaning of beneficence.an illustration is resuscitating a suffocating casualty. On the other hand, no-maleficence intends "no mischief." Physicians must avoid giving inadequate medications or acting with noxiousness toward patients. This standard, in any case, offers minimal helpful direction to doctors subsequent to numerous valuable treatments likewise have genuine dangers. The appropriate moral issue is whether the advantages exceed the weights. Doctors ought not to give insufficient medicines to patients as these offer danger with no probability of advantage and along these lines have a possibility of hurting patients (Gabaldón & Aguilera, 2008). Moreover, doctors should not do anything that would intentionally hurt patients without the activity being adjusted by relative advantage. Since numerous solutions, systems, and intercessions reason hurt notwithstanding advantage, the rule of non-perniciousness gives minimal solid direction under the watchful eye of patients. An illustration from my practice is halting a solution that is appeared to be destructive

I cannot agree more that in situations like these, bioethics must take on a paternalistic approach. While I usually feel anything overtly paternalistic can undermine ethics, it does have significant value in certain cases. In the example you provide of the 18 year old adolescent wishing to die rather than lose her hair, I would affirm that this is a shining instance where paternalism is needed. Dworkin (2014) offers that paternalism helps question how a person “should be treated when they are less than fully rational” (paragraph one). It would go without much opposition that the adolescent in your example is not fully rational. It is at this point where medicine needs to project a more paternalistic approach. I would contend that this is where

Imagine you are injured or sick and have sought a doctor’s help. Although you trusted your doctor, something, something seemingly very in control of the doctor, went wrong. You are angry and confused, but also think of the commonality of medical malpractice. So, why do doctors, who are supposed to help, harm? Though many flaws influence it, malpractice can be, and often is unintentional. Most doctors aren’t trained to harm their patients. Inexperience and lack of medical discovery led to unintentional suffering of the patient. Personal flaws, like lack of willingness to abandon previous medical methods and shortcomings in communication also harm patients. Further reasons why doctors harm are socio-medical understandings that breed hate, prejudices stemming from a society’s belief about certain people, such as the medical practice under the Nazi regime. Additionally, displayed in the case of Ignác Semmelweis, judgement of one to oneself can be detrimental to any progress one’s ideas could make. We will examine these concepts through Jerome Groopman’s “Flesh-and-Blood Decision Making”, Sherwin Nuland’s The Doctors’ Plague and Barbara Bachrach’s “In the Name of Public Health”. Those who practice medicine are, unfortunately, unfree from the imperfections that plague all of humanity. Through these intimate and varied faults, doctors do harm.