Paternalism, autonomy and responsibility in the medical setting

This dissertation examines three concepts in the context of the medical setting: paternalism, autonomy and personal responsibility. Paternalism is addressed solely as a characteristic mode of medical thought and activity structuring the relationships of physicians and patients. The moral appropriateness of paternalism as a privately negotiated, individually accomplished behavior is not directly analyzed. Critical discussion of a number of prominent definitions of paternalism is provided. Analysis of these definitions supplies the materials for the welding of a comprehensive definition. The history of paternalism in medicine is detailed. It is argued that paternalism historically has not been reserved as a tool for use in special or rare instances, but represents a persistently employed templet for the general organization of medical practitioners' dealings with patients. The influence of structural aspects of the organization of medicine, the nature of illness and patient-physician use of language on the expression of paternalism is explained. Clinical illustrations of institutional paternalism are provided. The moral status of this practice is considered. A principle is constructed detailing the compass of morally justified paternalism. Paternalism as an organizational institution is shown to be beyond the pale of justified intervention. It is demonstrated that the reality of institutional paternalism is inconsistent with the goals paternalism professes, the production of patient benefit.

Three major categories of definitions of autonomy are analyzed: autonomy as free and individually chosen action; as free and rational action, and as authenticity. The components of these characterizations are analyzed, the adequacy of each definition is assessed. An eclectic definition of autonomy is introduced and defended.

The notion of personal responsibility is considered in light of the problem of high-risk health behaviors. The issue of the requirements of personal responsibility in this context is viewed as a nexus of confrontation of three different socio-moral principles, paternalism, social utility and autonomy. Three major categories of high-risk behaviors are detailed. Consideration is given to factors which might underlie high-risk behaviors and various techniques proposed for dealing with such activity.