How to reveal disguised paternalism: version 2.0

Background We aim to further develop an index for detecting disguised paternalism, which might influence physicians’ evaluations of whether or not a patient is decision-competent at the end of life. Disguised paternalism can be actualized when physicians transform hard paternalism into soft paternalism by questioning the patient’s decision-making competence. Methods A previously presented index, based on a cross-sectional study, was further developed to make it possible to distinguish between high and low degrees of disguised paternalism using the average index of the whole sample. We recalculated the results from a 2007 study for comparison to a new study conducted in 2020. Both studies are about physicians’ attitudes towards, and arguments for or against, physician-assisted suicide. Results The 2020 study showed that geriatricians, palliativists, and middle-aged physicians (46–60 years old) had indices indicating disguised paternalism, in contrast with the results from the 2007 study, which showed that all specialties (apart from GPs and surgeons) had indices indicating high degrees of disguised paternalism. Conclusions The proposed index for identifying disguised paternalism reflects the attitude of a group towards physician assisted suicide. The indices make it possible to compare the various medical specialties and age groups from the 2007 study with the 2020 study. Because disguised paternalism might have clinical consequences for the rights of competent patients to participate in decision-making, it is important to reveal disguised hard paternalism, which could masquerade as soft paternalism and thereby manifest in practice. Methods for improving measures of disguised paternalism are worthy of further development.

Paternalism: A Flawed Basis for Liberty-limiting Policies?

This article discusses coercive paternalism, a concept of liberty-limitations that has gained significant attention in recent decades. In opposition to the libertarian type of paternalism proposed by the well-known ‘Nudgers’ Richard H. Thaler and Cass R. Sunstein (2008), Sarah Conly (2013) advocates coercive interventions in Against Autonomy: Justifying Coercive Paternalism. Her influential work serves as a basis for scrutinizing the validity of coercive paternalism’s presuppositions as well as the internal coherence of the concept. Following the fundamental groundwork of especially Joel Feinberg and Gerald Dworkin, arguments against coercive paternalism are evaluated. They include the reciprocal (rather than unilateral) relationship between the ‘present self’ and the ‘future self’ in the paternalist’s account, the questionable legitimacy of punishment for self-harming behaviour and of coercion in general, the challenges of so-called ‘perfectionism’ and slippery-slopes, as well as a misconception about the alleged lack of rationality that serves as a justification for coercive paternalism. The article concludes by suggesting that – given the flaws of the concept – it may be reasonable to favour soft paternalism à la John Stuart Mill based on the harm principle over Conly’s proposal for a more extensive form of coercive paternalism.

How to Reveal Disguised Paternalism – Version 2.0

Objectives: To further develop an index for detecting disguised paternalism, which might influence physicians’ evaluations of whether or not a patient is decision competent at the end of life. Disguised paternalism can be actualized when physicians transform hard paternalism into soft paternalism by denying the patient’s decision-making competence. Methods: A previously presented index was further developed to make it possible to distinguish between high and low degrees of disguised paternalism using the average index of the whole sample. We recalculated the results from a 2007 study to compare to a 2020 study. Both studies are about physicians’ attitudes towards, and arguments for or against, physician assisted suicide (PAS). Results: The 2020 study showed that geriatricians, palliativists and middle aged physicians (46-60 years) had indices indicating disguised paternalism, in contrast with the results from the 2007 study, which showed that all specialties (apart from GPs, surgeons and older physicians) had indices indicating high degrees of disguised paternalism.Conclusions: The proposed index for identifying disguised paternalism reflects the attitude of a group attitudes towards physician assisted suicide. The indices make it possible to compare the various medical specialties and age groups from the 2007 study with the 2020 study. Because disguised paternalism might have clinical consequences for the rights of competent patients to participate in decision-making, it is important to reveal disguised hard paternalism, which could masquerade as soft paternalism and thereby manifest in practice.

Addressing the dilemma of India’s state dependency on Alcohol: ‘New-Soft’ Paternalism approach

Indian states have alcohol policies ranging from strict prohibition to high taxation and overregulation. A pernicious effect of prohibition, in particular, has been the clogging of judiciary, disproportionate impacts on the poor and marginalized and diversion of already limited state capacities. In this article, we examine the role of state policy in India in addressing alcoholism’s deleterious impacts such as economic hardships, domestic violence and high disease burden. We have traced the current policy ambivalence to India’s history with attitudes ranging from permissiveness, colonial-era commodification to prohibition. We argue that India’s current alcohol policy can be understood as a combination of ‘old’ paternalism built on moral-religious ideas and ‘hard’ paternalism where the state interference overrides conscious choice of individual agent. We propose a ‘new-soft,’ post colonial framework which strikes a balance between individual choice, public health, gender parity and state revenues while eschewing disproportionate prosecution and punishment.

Beyond paternalism: Plea for the de-paternalization of children’s protection and participation

When aiming at characterizing the quasi-colonial or adultist relationship between adults and children, the concept of paternalism is often applied. The term is used in different ways, and this chapter intends not only to present it, but also to determine to what extent it is really apt to analyse, qualify and design the relationships between adults and children in different social and cultural contexts. To this end, it places particular emphasis on issues of child protection and child participation. First, the chapter explains the concept of paternalism and questions the arguments with which the so-called pedagogical paternalism or soft paternalism is usually justified. Secondly, it analyses to what extent the rights of children and certain variants of paternalism can be compatible or contradictory. Then the chapter explains with regard to several examples of child protection and child participation, how they are marked by paternalist thought patterns and how these can be overcome.

Physicians in the double role of treatment provider and expert in light of principle-based social insurance medical ethics

GPs serve in a double role of treatment provider and expert in certain social insurance systems, such as the Norwegian one. Some physicians assert that the ethical obligations of the two roles conflict with each other. The objective of this article is to show that social insurance medical ethics (SIME), which are based on recognised principles of medical ethics, unite the physicians’ obligations associated with these roles. The method applied is a medical ethics conceptual analysis. The material consists of literature on normative SIME. The study shows that SIME expands the role of the treatment provider to a wider societal context. Here, physicians should attempt to balance the perspectives of sympathy with empathy, as treatment providers, with the impartiality in their role as experts. Five principles of medical ethics are fundamental. Respect for human dignity is the overarching principle of medical ethics. The four others are nonmaleficence, beneficence (including soft paternalism), autonomy, and social justice. The article discusses two areas where it is asserted that the roles of treatment provider and expert conflict with each other: the application of beneficence and justice, and the duty of confidentiality versus the duty to provide information to the National Insurance service. The study concludes that there are no basic ethical conflicts between the two roles. The ethical problems that may arise when exercising this duality should be viewed in the same way as other ethical problems in medicine. Actual application and balancing of the principles may necessitate negotiations between patients and physicians. Keywords: dual roles, professionalism, deliberation, impartiality, medical principle ethics, values of welfare state

Ulysses Contracts in psychiatric care: helping patients to protect themselves from spiralling

This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment (time 2), they may still be less competent than they were when they signed the Ulysses Contract (time 1). As such, even if competent at time 1 and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people’s most meaningful concerns. Third, on the approach defended, the restrictions to people’s liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis (the claim that allowing harm is as bad as doing harm), this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary.