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An argument FOR paternalism
Goldman does not like argument one because it doesn't get rid of paternalism entirely - paternalism is justified on a case by case basis. But he wants to argue that paternalism is always wrong. So time for argument two - the moral argument.
It depends. Different patients may respond in different ways. Doctors cannot predict in advance how a patient will react.
Argument 1) The empirical argument. One could argue that it will not, in fact, lead to objective harm if we honour patients autonomy.
Premise 1) Granting autonomy is sometimes going to be detrimental to a patient's health, even leading to death.
Goldman thinks that paternalism is unjustified except in exceptional circumstances.
For Goldman, the problem with the argument for paternalism is premise 2. He thinks that sometimes health or life is not the absolute priority for patients. if health and life is always their top priority then paternalism is fine. But if other values come out on top, then paternalism for the sake of health or life is not justified.
Harm
Premise 2) Worsening health or death is something that patients would absolutely not want. They value health and life the most.
Utilitarian response - if you predict they will be harmed by autonomy, what should be done? If you predict they will not be harmed, what should be done?
"when a state of affairs below a certain level on his preference scale is realised than one higher up."
Argument 2) The moral argument. One could argue that honouring ther autonomy does objectively harm patients, but that interfering with their autonomy is always a greater harm. In other words, inclusive harm is worse than objective harm. This is what Goldman goes for.
To make his argument strong, Goldman looks at cases where we know that a patient will be harmed by autonomy. Is the harm bad enough to justify paternalism? If the harm is bad enough, then paternalism is permissible. If not, then paternalism is not allowed.
P.94.
Conclusion: Therefore paternalism is justified. Doctors may override autonomy to prevent the harm of death/illness.
Inclusive harm
Objective harm
Paternalism is thus justified for some patients and not for others. If a patient really is harmed by autonomy then paternalism is fine.
Something that is so bad most of us would consider it to be a step down, and would want to avoid it. Example?
When our ability to choose is blocked. We can be harmed in this way whether we realise it or not, and even if our desires are not frustrated.
Goldman wants to counter this argument (think about what premise you would attack)
Note that doctors always place health/life on top. Goldman thinks that autonomy is always going to be our top interest. Why?
Autonomy does not = the patient can choose whatever they like.
1) The spouse chooser
Is life valuable in and of itself? Goldman argues no. Why not?
Goldman argues that most of us do not just value bare life - mere existence. For most people the quality and enjoyment of life is more important than simply living.
Wanglie case - is it reasonable/unreasonable to cryopreserve her?
Who decides what is in the scope of medicine?
3) is the most tricky - how do we decide what is outside the scope of medicine?
Case of Jewel Shuping (see bonus material)
3 limitations on medical treatment.
Story of a guy who wants his healthy arm removed. It's his arm, his values - should the doctor respect his choice?
He argues that if all doctors refuse to do something that is strong evidence that it is outside the proper scope of medicine.
Doctors are thus wrong to assume that life and health are of paramount importance to patients. Some patients may have different values. In being paternalistic for health reasons, the doctor is making choices that clash with the patient's own values and interests.
Jewel chose to blind herself.
She found a doctor who
was willing to blind her.
1) May not be treated by non medical means.
Can you think of a problem with this view?
He thinks that the ability to make our own decisions "is so important that normally no amount of other goods, pleasures, or avoidance of personal evils takes precedence."
Imagine a computer program that could choose a perfect spouse for you. Most of us would prefer to choose for ourselves, even though our choices wouldn't be as good as the computer's! Goldman thinks this shows we value freedom above all other things.
2) May not be given futile treatment
Many doctors in the past agreed that lobotomy was in the proper scope of medicine. Were they right? Maybe doctors get this wrong!
Wanglie case: 89 year old woman, on life support, in permanent coma. Is it reasonable/unreasonable to continue with life support?
This was not an issue of futility. The treatment was not futile - it was keeping her alive. This was a case about whether it was within the proper remits of medicine to keep her alive. Was keeping her alive like cryopreservation or arm case?
1) What would Goldman
say?
2) What would Schwartz say?
We think that autonomy means you can make a choice unconstrained by the values of the doctor. But in this case, we think the doctor shouldn't do it!
Life in a coma no better than death.It is the quality of life that counts not just being alive. A life in constant depression and pain is not valued.
3) May not be treated in ways that are outside the scope/goals of medicine
We value autonomy for its own sake.
Do you agree?