Consent or Caring? Issues of Autonomy and Paternalism in the Treatment of Anorexia Nervosa

<p>Denial is a characteristic feature of anorexia nervosa (AN) that may lead to treatment refusal. If an individual is refusing treatment autonomously, it should be accepted, while a lack of autonomy indicates paternalistic intervention may be justified. AN has the highest mortality rate of any mental disorder, so accepting refusal means accepting the risk of death, so should only be done with the certainty that it is autonomous. The current research is theoretical, reviewing the literature on ethical issues relating to autonomy and paternalism in AN in order to evaluate the evidence base for these assumptions. The aim is to develop a procedural model for establishing autonomy in those with AN. The result is the anorexia nervosa autonomous decision-making model (ANDMM), which provides guidance for responding to autonomous and non-autonomous treatment refusal.</p>

Consent or Caring? Issues of Autonomy and Paternalism in the Treatment of Anorexia Nervosa

<p>Denial is a characteristic feature of anorexia nervosa (AN) that may lead to treatment refusal. If an individual is refusing treatment autonomously, it should be accepted, while a lack of autonomy indicates paternalistic intervention may be justified. AN has the highest mortality rate of any mental disorder, so accepting refusal means accepting the risk of death, so should only be done with the certainty that it is autonomous. The current research is theoretical, reviewing the literature on ethical issues relating to autonomy and paternalism in AN in order to evaluate the evidence base for these assumptions. The aim is to develop a procedural model for establishing autonomy in those with AN. The result is the anorexia nervosa autonomous decision-making model (ANDMM), which provides guidance for responding to autonomous and non-autonomous treatment refusal.</p>

Patient Protection and Paternalism in Psychotherapy

This chapter provides a synthetic overview of the ethics of paternalism in psychotherapy with a focus on involuntary hospitalization to protect patients from self-harm. Paternalism entails the intentional overriding of someone’s preferences or actions on grounds of beneficence and nonmaleficence. After the emergence of autonomy in medical ethics, paternalism is generally considered prima facie wrong, as it infringes on patient autonomy, trust, and right to informed consent. In particular, the use of paternalism in psychotherapy raises a host of complex and delicate ethical issues due to the nature of the therapeutic relationship and the difficulty to assess the autonomy of the person who will supposedly benefit from the paternalistic intervention.

Promises and perils of Guan

This article examines families’ involvement in the care and management of people with serious mental illnesses in China, and focuses on how that involvement is shaped by changing psychiatric institutions and law. Drawing on 32 months of fieldwork, I show that familial involvement is primarily characterised by guan [管], which can mean ‘care’ and/or ‘control’, and which commonly invokes a particular cultural ideal of parenting. Tracing how the language and practice of guan circulate between different realms, I argue that a ‘biopolitical paternalism’ has emerged in contemporary China. It reduces patients to carriers and manifestations of biomedical/security risk and legitimises the state’s policy of population management as a form of paternalistic intervention, while displacing certain paternalistic responsibilities, such as hospitalisation and ensuring medication compliance, onto patients’ families. This biopolitical paternalism produces vulnerabilities and unease within families and aggravates health disparities between patients. The analytic of biopolitical paternalism has conceptual efficacy and practical implications beyond mental health.

Paternalism and Individual Freedom

The growth of state bureaucracy is seen by many as a threat to individual freedom. This concern has been mitigated in part by the commitment of the liberal state to refrain from engaging in paternalistic intervention. This chapter revisits John Stuart Mill’s classic arguments against paternalism to assess recent challenges to the traditional liberal deference of individual autonomy. The discovery of systematic deviations from rationality has suggested to many that state officials may in certain cases be able to improve individual welfare by intervening in ways that override individuals’ own judgment. These proposals can be analyzed under three categories: those having to do with temporal distortions of preference, with biases in cognition, and with manipulation of choice through non-rational means. This suggests certain valid exceptions to the general rule laid down by Mill.

Duties to Respect Patients’ Autonomy and Assess Capacity

The two interrelated duties of respecting autonomy and assessing decisional capacity require considerable explanation. The first is acknowledged as a duty in most contemporary codes of medical ethics, while the second is not mentioned in any. This chapter provides a description of three distinct uses of the concept of autonomy and an overview and critique of different traditional and contemporary philosophers’ views on the concept of autonomy. To be trusted, doctors have to pay serious attention to patients’ opinions on what is good for them. They also have to recognize their fiduciary responsibility, step back from respectfully presuming that patients have autonomy, assess decisional capacity, and determine whether patients can be held responsible for their choices. Autonomous decisions should be respected, but when decisional capacity is impaired, paternalistic intervention may be required. Examples provide doctors with guidance for making the challenging decisions related to decisional capacity that have to be made in clinical practice.

Hard incompatibilism and the participant attitude

Following P. F. Strawson, a number of philosophers have argued that if hard incompatibilism is true, then its truth would undermine the justification or value of our relationships with other persons. In this paper, I offer a novel defense of this claim. In particular, I argue that if hard incompatibilism is true, we cannot make sense of: the possibility of promissory obligation, the significance of consent, or the pro tanto wrongness of paternalistic intervention. Because these practices and normative commitments are central to our relationships as we currently conceive of them, it follows that hard incompatibilism has radically revisionary conclusions.

Misapplication and Individuality

This chapter critically examines two of John Stuart Mill’s consequentialist objections to paternalism: that paternalistic authority is likely to be misapplied or abused and that intervention in the self-regarding sphere threatens individuality and self-development. It is argued here that both objections can be resisted. Concerns about misapplication and abuse pose no challenge to intervention that is likely to succeed in achieving its benevolent aims, and attempts to avoid this problem by construing Mill’s arguments in rule-consequentialist terms are unconvincing. Concerns about Millian individuality or self-development leave considerable room for justified paternalism, both because individuality is not the only component of well-being and because paternalistic intervention can sometimes promote individuality. Mill’s arguments may show that there ought to be some institutional constraints on the government’s ability to intervene in the self-regarding sphere, but defenders of paternalism can happily accept this result.

Paternalism and Moderate Deontology

This chapter attempts to situate pro-paternalism within a moderate deontological moral theory. According to moderate deontologists such as Judith Jarvis Thomson, moral rights have thresholds beyond which they can be permissibly infringed. According to one plausible way of developing this view, a right has a threshold of zero when its infringement would benefit the right-bearer. If so, then beneficial paternalistic intervention may be permissible even if it infringes rights. After developing this argument, the chapter considers several possible anti-paternalist replies, including the suggestion that rights thresholds are sensitive to the value of autonomy. It is argued that each reply either has implausible implications or is unlikely to support common anti-paternalist judgments about cases.