Dissertations / Theses on the topic 'Medical paternalism'

Introduction: The terms autonomy and paternalism can be conceptualized and analyzed from different perspectives. The most relevant for physicians in this study are the ethical and legal viewpoints. In order to conceptualize anything a definition to depart from is needed, in this case from Oxford’s dictionaries. The importance to reflect on ethical and legal matters as a physician is due to the power over the patient one has, and it must be respected and grounded in a motivated ethical principle, since all our actions arise from ethics, consciously and subconsciously. Aim: The aim is to analyze and discuss the relationship between paternalism and autonomy from a medical ethical perspective, in relevant Swedish laws and with regards to the ethical principles. Methods: This is a qualitative study on hermeneutic ground that used two different databases and libraries and sorted material according to relevance. Inevitably this leads to a bias due to the author’s previous knowledge and selected sources. Results, Discussion and Conclusion: Physicians tend to prioritize ethical arguments depending on the situation. Autonomy is one of the four ethical principles, and this is not always the most prioritized, but beneficence may be seen as a stronger argument for action. Also, there are more regulations to secure the patient’s autonomy than the physician’s paternalism, leading to only indirect regulations towards paternalism. The conceptualization of paternalism and autonomy can be seen in many different ways, and are not always opposites as it can initially seem, but in some scenarios aline.

Medical paternalism is a common practice in Pakistan, it can be justified on the principles of beneficence and non-maleficence in certain clinical situations but in the research medicine it can pose many ethical implications.

Islam is a communitarian religion but it provides full autonomy to the competent individuals. Pakistan Medical and Dental Council (PM&DC) codes of ethics have been formulated in line with the World Medical Association and it also states in its preamble that it follows Islamic bioethical laws. The PM&DC guidelines do not provide substantial system for obtaining consent from patients and the research participants. Neither does it comply with the Islamic bioethical laws nor with the International Declarations. The language used in the codes is ambiguous that can have different interpretations and there is no legal support from the civil law of the country. These factors supplemented with the cultural values have elevated the status of the physician and gives complete authority to them for medical decisions.

Medical paternalism in research medicine can be a violation of the dignity and autonomy of the research participants. Patients are used as means and commodities rather than end in themselves. The research involves risks of harms no matter how low these risks are – the matter of concern is that research participants are involved in research accompanied with risks about which they are not aware.

Region Östergötland has encountered issue in ecological and economical overconsumption of single-used garments in healthcare sector among medical staff in Universitetssjukhuset Linköping. Proper approaches to reach solutions towards decrease of usage of single-used garments were targeted to be implemented for employees of healthcare sector. Two goals were established for this study. First of all, it was aimed to analyse consumer behaviour of employees in healthcare sector of Östergötland region to find out reasons that lay behind increase of single-time garments by employees. Secondly, the aim was targeted to examine what nudging techniques, if any, are feasible to use in positively changing current consumer behavior. The findings showed that nudging has a strong potential to be regarded as an effective tool in influencing healthcare workers of Linköping University Hospital disposable garments usage. Main behavioural reasons that triggered increase of disposable garments usage were detected as lack of information and old habits of medical staff. Application of information disclosure, framing, feedback and social norms nudging techniques were identified to have promising possibilities in impacting current behaviour and raise healthcare workers awareness about their consumption patterns.

This thesis defends an individual's moral right to be aided in dying by a physician (that is, voluntary active euthanasia, or VAE), but departs significantly from the view in its favor generally accepted in the bioethics literature. The prevailing view appeals to both respect for an individual's autonomy and promotion of an individual's well-being as necessary conditions for a right to VAE, so as to justify the right only for those suffering grave illnesses and/or disabilities. The author argues that such a view is logically untenable; one or another aspect must be given up. Since invoking the premise that certain individuals would be better off dead necessarily relies on controversial assumptions about both the value of life and the nature and value of death, about which reasonable people disagree, it is the justification from an individual's best interest which must be excluded in a liberal society. The author endorses a self-determination justification for the right to VAE, but rejects understanding this in terms of respecting personal autonomy, instead making the case for a right to VAE grounded in self-ownership. The author's main conclusion is that the right to VAE is a general right applying to all competent adults, not only those suffering grave illnesses or disabilities, or those whose choice for VAE is an exercise of autonomy. Moreover, by analyzing the basis of physician authority over prescription medicine and how this can be justified to a society of self-owners, she maintains that individuals have not only the right to choose VAE without state interference, but also the right to be provided VAE by doctors. Nevertheless, both rights are compatible with reasonable limitations to protect both the interests of VAE seekers and the rights of others.

xii, 163 p.
The principle of respect for autonomy has been the center of gravity for the doctor-patient relationship for forty years, replacing the previous defining concept of physician paternalism. In this work, I seek to displace respect for patient autonomy with narrative and phronesis as the skills that must be mastered by the physician to engender a successful therapeutic clinical relationship. Chapter I reviews the current state of affairs in the philosophy of medicine and the doctor-patient relationship and explains how and why autonomy has become so central to physicians' understanding of how to conduct a clinical encounter with a patient. Chapter II argues that "respect for autonomy," while remaining a valid rule to be considered in some clinical relationships, cannot be the central concept that defines the relationship both because it fails to describe accurately human selfhood and also because it empirically lacks universal applicability--many humans, and most seriously ill patients, actually lack autonomy. Shared decision making, an autonomy-based model of the doctor-patient relationship, suffers from this critique of autonomy as well as its own shortcomings in that it maintains a strict fact/value distinction that is untenable. Chapter III introduces narrative philosophy and its extrapolation, narrative medicine, as a possible alternative to an autonomy model of care. I defend a narrative view of selfhood, while recognizing that even if we are in some sense narratively constituted, this still leaves many questions regarding the relationship between story and self, particularly in a clinical encounter. In Chapter IV, I seek to limit the claims of narrative by arguing that story and self can never be fully equated and that narrative must be understood as demonstrating alterity rather than eliminating it. In Chapter V, a new conception of the physician's role in the doctor-patient relationship is presented, combining phronesis, or practical wisdom, with narrative skill in four aspects of the clinical encounter: diagnosis, treatment, assistance in medical decision making, and emotional support of the patient.
Committee in charge: Naomi Zack， Chairperson； Cheyney Ryan， Member； Mark Johnson， Member； Mary Wood， Outside Member

Thesis (MPhil)--University of Stellenbosch, 2003.
ENGLISH ABSTRACT: The health of the medical profession hangs in the balance. Scepticism, mistrust and legal restraints have entered its hallowed corridors and are threatening its integrity and independence. There are myriad seemingly intractable moral dilemmas that doctors, ethicists and judges are trying to resolve with the aid of available principles and rules of ethical discourse; yet, the answers remain elusive. Hegel, the eighteenth century philosopher, postulated that perplexity only exists because we do not look at the world correctly: because we tend to think in an oppositional way, we abstract from the complex interrelation of things. He therefore suggested that one should step back and think reflectively about the problem and seek the one-sided assumptions that led to the impasse. My proposition is that at the heart of many of the current medical dilemmas lies the opposition between paternalism and autonomy. These two fundamental concepts arose out of two different traditions, and now, because they have been abstracted from the contexts and histories that inform them, seem to be diametrically opposed. Paternalism arose out of the ethics of competence that originated in ancient Greece. The art of medicine was still in its infancy and physicians had to prove their ability and benevolence to a mistrustful public. Demonstration of competence became a necessary component of any successful practice. As the power of medicine grew with the scientific and technological advances of the Enlightenment, professionals' authority and competence were reinforced and systematically fostered a paternalistic attitude at the expense of adequate protection of the individual. In response to the power differential found in the political and social arena, individual human rights were promulgated in the eighteenth century. In the medical sphere, the culture of rights was translated into, among others, the fundamental right to autonomy. Patients now have the right to decide on interventions and treatment in accordance with their own conception of a good life. Paternalism thus developed out of a societal system that embraced the virtues and communal responsibility within the bounds of the polis of antiquity; autonomy arose out of the designs of the Enlightenment where the individual was hailed supreme. Remnants of both traditions are evident in contemporary medicine, but they have been abstracted from their original purpose and meaning, leading to perplexity and antagonism. Following the Hegelian method of dialectic, I postulate a thesis of paternalism, and in response to this, an antithesis of autonomy. I attempt to show that an intransigent insistence on one side or the other will only serve to strengthen the paradox and fail to lead to an acceptable solution. I aim to develop a synthesis where both concepts are embraced with the help ofa better understanding of human nature and the inevitable limits of human knowledge. Influenced by the work of the psychoanalyst Carl Jung, I firstly argue for the existence of a biological human need for compassion and thus the importance of virtue ethics, which embraces this need. Secondly, focusing on the ethics of futurity developed by Hans Jonas, I delineate the altered nature of human action and the derivative need for an ethics of responsibility. I propose possibilities for the future based on the ideas of compassion, virtue and responsibility and argue that they can only be reconciled in a pluralistic ethic.
AFRIKAANSE OPSOMMING: Die mediese professie het'n dokter nodig. Een wat kan sin maak van die wantroue en vyandigheid wat te bespeur is in die pasient-dokter verhouding en wat toepaslike terapie kan voorskryf Al die pogings tot behandeling deur middel van reëls, regulasies en etiese kodes het tot dusver misluk en het vele skynbaar-onoplosbare morele dilemmas agtergelaat. Die Duitse filosoof, Hegel, het in die agtiende eeu aangevoer dat verwarring onstaan bloot omdat ons die wêreld op die verkeerde wyse beskou: die mens is geneig tot opposisionele denke en neem daarom nie die komplekse onderlinge verbintenisse van die onderskeie elemente in ag nie. Hegel het dus voorgestel dat wanneer ons met sulke hardnekkige situasies gekonfronteer word, ons 'n tree terug neem en die situasie reflektiewelik ondersoek vir eensydige veronderstellings. My hipotese is dat baie van die etiese dilemmas wat op die oomblik in medisyne voorkom, voortvloei uit die opposisie tussen paternalisme en outonomitiet. Hierdie twee fundamentele beginsels het uit twee verskillende tradisies ontstaan en nou, omdat hulle nie meer in hulle oorspronklike konteks voorkom nie, vertoon hulle skynbaar teenstellend. Paternalisme het onstaan vanuit die etiek van bevoegdheid wat teruggevoer kan word na die tyd van Hippocrates. Medisyne was 'n nuwe professie wat nog sy eerbaarheid en welwillendheid aan 'n wantrouige publiek moes bewys. Bevoegdheid was dus 'n essensiële komponent van enige suksesvolle praktyk. Indrukwekkende vooruitgang in die dissiplines van wetenskap en tegnologie sedert die agtiende eeu het dokters se gesag en bevoegdheid bevorder en stelselmatig 'n paternalistiese houding gekweek ten koste van toepaslike beskerming van die individu. In respons tot die magsverskil in die politieke en sosiale sfeer het 'n beweging in hierdie tyd ontstaan om universêle mensseregte te bewerkstellig. In medisyne het hierdie regsbeweging gekulmineer in, onder andere, die fundamentele reg tot self-beskikking - in ander woorde, outonomiteit. Die pasient is dus nou geregtig daarop om selfte besluit oor ingrepe en behandeling op grond van sylhaar konsep van 'n goeie en sinvolle lewe. Paternalisme het dus ontstaan uit 'n samelewing waar die deugte en gemeenskapsverantwoordelikhede integraal was tot die funksionering van die polis; outonomie aan die ander kant, het ontstaan uit die idees van Die Verligting waar die individu as belangriker as die gemeenskap geag is. Volgens die Hegeliaanse dialektiese metode, postuleer ek dus 'n tesis van paternalisme en in respons daartoe, 'n antitese van outonomiteit. Ek voer aan dat 'n eiewillige aandrang op een of die ander die dilemma net sal verdiep. Ek poog dus om 'n sintese te ontwikkel wat albei konsepte inkorporeer met behulp van 'n analise van die aard van die mens en die noodwendige beperkinge van sy kennis. Geskool op die werk van die psigoanalis Carl Jung, bespreek ek die mens se biologiese behoefte aan medelye en stel dus die saak vir die belang van 'n etiek van deugte wat hierdie behoefte onderskraag. Tweedens, beinvloed deur die etiek van die toekoms, soos beskryf deur Hans Jonas, ontwikkel ek die idee van die gewysigde skaal van menslike dade en gevolglik die noodsaklikheid van 'n etiek van verantwoordelikheid. Ek postuleer dus 'n benadering wat wentel om die konsepte van medelye, deug en verantwoordelikheid wat slegs in die vorm van 'n pluralistiese etiek tot uiting kan kom.

Syftet med vårt arbete är att undersöka hur hemtjänstpersonal ser på problematisk alkoholkonsumtion i förhållande till självbestämmande bland äldre samt om det kan ha betydelse för deras omsorg av den äldre. Kvalitativa halvstrukturerade intervjuer genomfördes med hemtjänstpersonal (n=4) som analyserades hermeneutiskt utifrån teorier om makt och handlingsutrymme. Av resultaten framgår att självbestämmanderätten som Socialstyrelsen beskrivit den, är villkorad i hemtjänstpersonalens tolkning och att det saknas tydliga riktlinjer och rutiner i hemtjänstens arbete med äldre som har en problematisk alkoholkonsumtion. Resultaten visar att hemtjänstpersonalen gör individuella bedömningar i arbetet med äldre som har en problematisk alkoholkonsumtion. Det framgår att hemtjänstpersonalens arbete är förenat med svåra etiska ställningstaganden, där även maktförhållanden synliggörs och där hemtjänstpersonalen har tolkningsföreträde i förhållande till den äldre och förmynderi är en potentiell riskfaktor. En slutsats är att tydligare riktlinjer angående inköp av alkohol till äldre med en problematisk alkoholkonsumtion kan tänkas bidra till att hemtjänstpersonalen arbetar på ett mer likformigt sätt vilket i sin tur ökar rättssäkerheten för den äldre.
The aim of our study was to examine how integrity and self-determination is conceived by care assistants regarding older care takers with a problematic alcohol consumption, and if it affects their care provided. Qualitative semi-structured interviews, carried out with home care assistants (n=4) and analyzed hermeneutically with theories of power and discretion, showed that self-determination, as described by The Swedish National Board of Health and Welfare, is fulfilled only under certain conditions in the home care assistant’s interpretation. We also found a lack of guidelines and routines concerning problematic alcohol consumption among older care takers. Our results showed that home care assistants made individual assessments in their work with older care takers with problematic alcohol consumption actualizing a difficult ethical dilemma between neglect and paternalism. These ethical issues visualize power relationships where home care assistants have the prerogative to decide in relation to the care takers, where paternalism is a potential risk factor. Clear guidelines regarding the purchase of alcohol to older care takers with problematic alcohol consumption may contribute to home care assistants working more uniformly which leads to a higher state of legal security for the care takers.

James Joyce’s Ulysses celebrates all facets of daily life in its refusal to censor raw human emotions and emissions. He adopts a critically medical perspective to portray this honest, unfiltered narrative. In doing so, he reveals the ineffectiveness of the physician-patient relationship due to doctors’ paternalistic attitudes that hinder nonjudgmental, open listening of this unfiltered narrative. His exploration of the doctor’s moral scrutiny, cultural prejudices, and authoritative estrangement from the patient underscore the importance in remembering that physicians and patients alike are ultimately just fellow human beings. Wryly, he drives this point to literal nausea, as his narrative proudly asserts the revulsive details of public health, digestion, and death. In his gritty ruminations on the human body’s material reality, Joyce mocks the physician’s highbrow paternalism by forcing him to identify with the farting, vomiting, decaying bodies around him. In celebrating the uncensored human narrative, Joyce challenges physician and patient alike to openly listen to the stories of others.

Respect for autonomy has become the guiding principle at the forefront of health-care decision-making. In an attempt to preserve this principle, patients can be neglected to make decisions for themselves during times when they cannot make fully capable decisions. Under certain circumstances, it is necessary to have others assist a patient in making decisions that may have a significant impact on the patient’s life and, will ultimately, respect the patient's prior expressed capable wishes and values. This thesis aims to provide arguments in favor of both respect for autonomy and medical paternalism under very specific circumstances. It provides traditional, contemporary and psychological arguments in support of respect for autonomy. Several key arguments in favor of medical paternalism are also presented on the grounds of the loss of personal identity, a social insurance policy and the abandonment of vulnerable patients. Furthermore, the difficulties involved in both accounts are also discussed with respect to the idealization of autonomy and the potential abuses involved in medical paternalism. This thesis concludes through drawing upon the notion of an authentic self as applied to this discussion, allowing for a compatible defense of these two traditionally competing theories.

碩士
國立交通大學
科技法律研究所
101
In Taiwan, terminally ill patients are entitled to refuse life-sustaining treatment after the Hospice-Palliative Care act enacted in 2000. By formulating the act, government hopes that terminally ill patient can achieve a "good death". After enacted, the Act has been amended for 3 times and mainly focused on lawfully withdrawing life-sustaining interventions by third parties.The purpose of this study is to examine how patients’ right to refuse life-sustaining treatment be implemented under the Hospice-Palliative Care Act. By literature review and qualitative research, the author would like to investigate the international development of end-of-life issues and the legal response of Taiwan, the exercise of patient’s right to refuse life-sustaining treatment in current clinical practice, and the needed improvement. By conducting qualitative interviews with 14 intensive care unit physicians from 8 hospitals in Taiwan, the author found that patient’s wishes were rarely known for mostly being incompetent with no advance directives, thus it was mainly the patient’s family to make surrogate decision. Though the Act needs only one legal family surrogate to make decisions, if no consensus has been achieved among influential family members (not necessarily be qualified legal surrogate), the provision of life-sustaining treatment would not end. Since consensus among family members was the only rule for surrogate decision making process, health care provider might find inappropriate considerations, such as personal emotions and financial interests. According to the amendment of Hospice Palliative Care Act in 2013, health care provider could also make surrogate decisions based on patients’ best interest if no qualified family members could be find. Health care provider might consider whether the patient is curable, the quality of life and the burden of treatment is acceptable when making the judgment. For the reason that health care providers thought differently between “withdraw” and “withhold”, and interpreted the law conservatively, the result indicated that the new amendment would make little difference to current practice. In some cases, health care providers might identify surrogate’s request for life sustaining treatment as medically inappropriate for prolonging process of dying, being pointless, bringing pain or ultra burdens, bring no improvement and minimum chance of success. Although the interventions might make the patient suffered or consume medical resources, due to legal, psychological, social, cultural, and economical considerations, if the conflicts couldn’t be solved through communication or temporary attempt, these interventions would often be provided. As a result, the implementing rate of life-sustaining treatment became so high. Many health care providers agree with BNHI’s restriction as a solution, others suggest that health care providers should have the right to deny inappropriate request from surrogates. In order to protect patient’s right to refuse life sustaining treatment, the author found it necessary to broaden the scope of application of the Hospice-Palliative Care Act. Patients should be authorized to refuse life-sustaining treatment not only for prolonged dying process but also for unacceptable quality of life. It was also necessary to set implicit standard for durable power of attorney and surrogate to comply with when patient is incompetent. Patient’s wish should be the primary consideration, then his/her best interest. Though health care provider also could make surrogate decisions when patient was incompetent without any advance directive or qualified legal surrogate, the author found this new amendment might conflict the basis of the Hospice-Palliative Care Act, which is patient autonomy. Therefore, the amendment should be deleted. Based on professional integrity, the author also suggested health care providers to assist patient or their attorney and surrogate in decision-making by explaining medical considerations and providing recommendation, health care providers should also ask for second opinion whenever attorney or surrogate’s decision conflicts patient’s wish or best interest. Although BNHI’s restriction for “futile” treatments did reduce inappropriate use of life-sustaining treatment, the implication of medical futility should not be confused with rationing. Under medical futility circumstances, the health care provider no longer have absolute duty to follow individual’s choice or even have the duty not to comply with the request if the treatment carry no benefit or benefit with ultra burden. The theory had been provided to deal with the conflicts between professional judgment and personal request on the basis of nonmaleficience and beneficence, not medical resource allocation. To clarify the differences, BNHI should limit inappropriate use of life-sustaining treatment by other rationing standards. The author also encouraged health care providers continue to discuss the definition and ethical implication of medical futility, to help general public recognize the limit of life-sustaining treatments.

Platonic Craft and Medical Ethics examines the Platonic theory of craft and shows its application to different ethical problems in medicine, both ancient and modern. I begin by elucidating the Platonic use of the term “craft” or “technē”, using especially the paradigmatic craft of medicine, and explicate a number of important principles inherent in his use of the term. I then show how Plato’s framework of crafts can be applied to two ancient debates. First, I show how Plato’s understanding of crafts is used in discussing the definition of medicine, and how he deals with the issue of “bivalence”, that medicine seems to be capable of generating disease as well as curing it. I follow this discussion into Aristotle, who, though he has a different interpretation of bivalence, has a solution in many ways similar to Plato’s. Second, I discuss the relevance of knowledge to persuasion and freedom. Rhetors like Gorgias challenge the traditional connections of persuasion to freedom and force to slavery by characterizing persuasion as a type of force. Plato addresses this be dividing persuasion between sorcerous and didactic persuasion, and sets knowledge as the new criterion for freedom. Finally, I discuss three modern issues in medical ethics using a Platonic understanding of crafts: paternalism, conclusions in meta-analyses and therapeutic misconceptions in research ethics. In discussing paternalism, I argue that tools with multiple excellences, like the body, should not be evaluated independently of the uses to which the patient intends to put them. In discussing meta-analyses, I show how the division of crafts into goal-oriented and causal parts in the Phaedrus exposes the confusion inherent in saying that practical conclusions can follow directly from statistical results. Finally, I argue that authors like Franklin G. Miller and Howard Brody fail to recognize the hierarchical relationship between medical research and medicine when they argue that medical research ethics should be autonomous from medical ethics per se.