The present study aims to explore the forms paternalistic communication can take in doctor–patient interactions and how they should be considered from a normative perspective. In contemporary philosophical debate, the problem with paternalism is often perceived as either undermining autonomy (the autonomy problem) or the paternalist viewing their judgment as superior (the superiority problem). In either case, paternalism is problematized mainly in a general, theoretical sense. In contrast, this paper investigates specific doctor–patient encounters, revealing distinct types of (...) class='Hi'>paternalistic communication. For this study, I reviewed videorecorded encounters from a Norwegian hospital to detect paternalism—specifically, doctors overriding patients' expressed preferences, presumably to benefit or protect the patients. I identified variations in paternalistic communication styles—termed paternalist modes—which I categorized into four types: the fighter, the advocate, the sympathizer, and the fisher. Drawing on these findings, I aim to nuance the debate on paternalism. Specifically, I argue that each paternalist mode carries its own normative implications and that the autonomy and the superiority problems manifest differently across the modes. Furthermore, by illustrating paternalism in communication through real‐life cases, I aim to reach a more comprehensive understanding of what we mean by paternalistic doctors. (shrink)

Typically the justification of criminal statutes is based on "liberty-limiting principles" -- e.g., the Harm Principle, the Offense Principle, Legal Paternalism, Legal Moralism, etc. Two philosophers of the criminal law, however -- Richard J. Arneson and Cass R. Sunstein -- take an entirely different tack. Both countenance the use of the criminal law to foreclose one's future options, seeking to preserve one's "true self" from the temptations of one's baser desires. (For reasons which become clear, I call this "community self-paternalism".) (...) In this paper, I take a careful look at "community self paternalism"; scrutiny reveals that this proposed justification of criminalization is quite different from its initial appearance. Revealing its true character dispels much of its initial appeal. I then argue for its rejection; of necessity, "community self-paternalism" treats some individuals as means merely, and not as ends in themselves. (shrink)

Epistemic paternalism involves interfering with the inquiry of others, without their consent, for their own epistemic good. Recently, such paternalism has been discussed as a method of getting the broader public to have more accurate views on important policy relevant matters. In this paper, I discuss a novel problem for such paternalism—what I call epistemic spillovers. The problem arises because what matters for rational belief is one’s total evidence, and further, individual pieces of evidence can have complex interactions with one (...) another. Because of this, I argue that justified epistemic paternalism requires the would-be paternalist to be in an unusually strong epistemic position, one that most would-be paternalists are unlikely to meet. (shrink)

There is a correlation between positions taken on some scientific questions and political leaning. One way to explain this correlation is the cultural cognition hypothesis (CCH): people's political leanings are causing them to process evidence to maintain fixed answers to the questions, rather than to seek the truth. Another way is the different background belief hypothesis (DBBH): people of different political leanings have different background beliefs which rationalize different positions on these scientific questions. In this article, I argue for two (...) things. I argue that two attempts by proponents of the CCH to discredit the DBBH fail. And I argue that this matters, because while the CCH makes epistemic paternalistic interventions seem called for (as some philosophers have argued compellingly), the DBBH does not. The DBBH makes it much easier to stay closer to an ideal of deliberative democracy. (shrink)

BackgroundPaternalism/overprotection limits communication between healthcare professionals and patients and does not promote shared therapeutic decision-making. In the global north, communication patterns have been regulated to promote autonomy, whereas in the global south, they reflect the physician’s personal choices. The goal of this study was to contribute to knowledge on the communication patterns used in clinical practice in Mexico and to identify the determinants that favour a doctor–patient relationship characterized by low paternalism/autonomy.MethodsA self-report study on communication patterns (...) in a sample of 761 mental healthcare professionals in Central and Western Mexico was conducted. Multiple ordinal logistic regression models were used to analyse paternalism and associated factors.ResultsA high prevalence (68.7% [95% CI 60.0–70.5]) of paternalism was observed among mental health professionals in Mexico. The main determinants of low paternalism/autonomy were medical specialty (OR 1.67 [95% CI 1.16–2.40]) and gender, with female physicians being more likely to explicitly share diagnoses and therapeutic strategies with patients and their families (OR 1.57 [95% CI 1.11–2.22]). A pattern of highly explicit communication was strongly associated with low paternalism/autonomy (OR 12.13 [95% CI 7.71–19.05]). Finally, a modifying effect of age strata on the association between communication pattern or specialty and low paternalism/autonomy was observed.ConclusionsAmong mental health professionals in Mexico, high paternalism prevailed. Gender, specialty, and a pattern of open communication were closely associated with low paternalism/autonomy. Strengthening health professionals’ competencies and promoting explicit communication could contribute to the transition towards more autonomist communication in clinical practice in Mexico. The ethical implications will need to be resolved in the near future. (shrink)

While this paper does not explicitly define the concept of autonomy, the way Ubel et al describe clinicians’ failures to enhance their patients’ autonomy reflects a broader understanding of autonomy than the default account as free and informed choice. In this OPC I would demonstrate that the communication strategies the authors recommend reflects a more sophisticated conception of autonomy than the understanding that typically prevails in bioethics. I will also distinguish between weak and strong forms of paternalism, and argue (...) that a weak paternalistic approach is not only defensible but also aligns with the strategies the authors propose. Thus, by clarifying the concept of autonomy we can show how it can be enhanced in practice. (shrink)

Compared with children, adults are widely assumed to possess more mature moral understanding thus justifying deference to their moral authority and testimony. This paper examines philosophical discussions regarding this child-adult moral relation and its implications for moral education, particularly accounts suggesting that the moral status of children constitute grounds for treating them paternalistically. I contend that descriptions and justifications of this paternalistic attitude towards children are either unacceptably crude or mistaken. While certain instances justify paternalistic treatment towards children, (...) in the context of moral education the paternalistic attitude is largely irrelevant and even counterproductive. I make a case that children can readily meet minimal standards for moral understanding and engagement. Even when children have no final say, there is still a significant normative difference between deferring paternalistically to the adult's moral testimony and interacting with the child in moral conversation. These considered, I defend a social-contextualist account of moral education that incorporates a participatory (over a paternalistic) pedagogical attitude. Further, instead of portraying moral education in terms of stages (as argued by Kohlberg), moral education should be characterized more as a gradual appreciation of and sensitivity to normative demands that apply in various shared contexts and spheres of human concern. (shrink)

This volume considers forms of information manipulation and restriction in contemporary society. It explores whether and when manipulation of the conditions of inquiry without the consent of those manipulated is morally or epistemically justified. The contributors provide a wealth of examples of manipulation, and debate whether epistemic paternalism is distinct from other forms of paternalism debated in political theory. Special attention is given to medical practice, science communication, and research in science, technology, and society. Some of the contributors argue (...) that unconsenting interference with or "conceptual engineering" of people’s beliefs and ability of inquire is consistent with, and others that it is inconsistent with, efforts to democratize knowledge and decision-making. (shrink)

Schonsheck attacks views which seek to justify the majority of citizens of a society passing legislation that is designed to serve the purpose of preventing their own first order preferences from changing over time . The issue that I think is more important is a related one, but not precisely the same. It is not whether it is morally permissible for the majority of members of a society to pass legislation designed to prevent their own individual preferences from changing over (...) time, but whether it is morally permissible for them to pass legislation for the sake of preventing the community's preferences from changing over time. As some people mature and acquire preferences and others die, no individual's already-formed preferences have to change for the community's preferences to change. The arguments concerning these two issues are the same, or at least similar, but putting the matter the way I do, raises the question of influencing the preferences of children. I argue that there is nothing intrinsically wrong with a community's doing this and that Schonsheck's arguments to the contrary either are not convincing, or apply in some cases but not in others. (shrink)

I take as my starting point the “one very simple principle” proclaimed by Mill in On Liberty … “That principle is, that the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. He cannot rightfully be compelled to do (...) or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right.”. (shrink)

In contemporary paternalism literature, persuasion is commonly not considered paternalistic. Moreover, paternalism is typically understood to be problematic either because it is seen as coercive, or because of the insult of the paternalist considering herself superior. In this paper, I argue that doctors who persuade patients act paternalistically. Specifically, I argue that trying to persuade a patient (here understood as aiming for the patient to consent to a certain treatment, although he prefers not to) should be differentiated from trying (...) to convince him (here understood as aiming for the patient to want the treatment) and recommending (the doctor merely providing her professional opinion). These three forms of influence are illustrated by summaries of video-recorded hospital encounters. While convincing and recommending are generally not paternalistic, I argue that persuasion is what I call communicative paternalism and that it is problematic for two reasons. First, the patient’s preferences are dismissed as unimportant. Second, the patient might wind up undergoing treatment against his preferences. This does not mean that persuasion always should be avoided, but it should not be undertaken lightly, and doctors should be aware of the fine line between non-paternalism and paternalism. The fact that my analysis of paternalism differs from traditional accounts does not imply that I deem these to be wrong, but rather that paternalism should be considered as a more multi-faceted concept than previous accounts allow for. (shrink)

ABSTRACT If it could be shown that law is, in some sense, a moral system the apparent contradiction between (moral) autonomy and (legal) heteronomy might be challenged. In order to prepare for such a challenge this paper questions the prevailing view that law is not in the business of enforcing morals. That is done primarily by using decisions of the criminal courts to show that the law does not always criminalise conduct merely to prevent harm to others. Paternalism is distinguished (...) from the harm principle in order to show that the law (rightly or wrongly) sometimes seeks to secure that which is (thought to be) morally good, irrespective of the prevention of harm, at least overall harm. If such an insight is well founded there are consequences for legal theory in that neither of the ruling paradigms (naturalism and positivism) seems able adequately to accommodate the view of law which emerges. Consequently, an attempt is made in the essay to develop a middle theory of law, between naturalism and positivism, which is referred to as ‘normative positivism‘. The theory presented has, in turn, consequences for political practice. If law can be seen as community morality rather than as merely the morality of officials, then everyone has a stake in the moral content of law and there may be good moral reasons for disobeying official laws. Civil disobedience is the citizen's ultimate resort against the official morality that has appropriated to itself the eulogistic name of ‘law‘. That law may be seen as community morality also calls into question some ruling paradigms as to the nature of morality but, if the claim can be sustained, then the legal system may be seen as applied moral philosophy in action. (shrink)

Expatriate managers of international businesses in emerging countries often struggle to mobilize their workforces. They sometimes perceive profound cultural differences as a barrier to the progress of their organizations. Some international businesses may adopt a paternalistic attitude toward their employees; but this questionable strategy brings mixed results. Are there ways out of paternalism for international businesses in emerging areas? This paper examines the diverging views held by foreign managers and local personnel of a foreign-owned production plant in Mexico, which (...) managed to mobilize its workforce by building a strong sense of community, allowing a certain form of collective control to replace the paternalistic model, with its bonds of personal allegiance. Contrasting perspectives between Mexican and foreign employees show that intercultural misunderstandings, rather than the peculiarities of the local culture, are the greatest challenge to cooperation. (shrink)

In this article I defend a rule utilitarian approach to paternalistic policies in research with human participants. Some rules that restrict individual autonomy can be justified on the grounds that they help to maximize the overall balance of benefits over risks in research. The consequences that should be considered when formulating policy include not only likely impacts on research participants, but also impacts on investigators, institutions, sponsors, and the scientific community. The public reaction to adverse events in research (such (...) as significant injury to participants or death) is a crucial concern that must be taken into account when assessing the consequences of different policy options, because public backlash can lead to outcomes that have a negative impact on science, such as cuts in funding, overly restrictive regulation and oversight, and reduced willingness of individuals to participate in research. I argue that concern about the public reaction to adverse events justifies some restrictions on the risks that competent, adult volunteers can face in research that offers them no significant benefits. The paternalism defended here is not pure, because it involves restrictions on the rights of investigators in order to protect participants. It also has a mixed rationale, because individual autonomy may be restricted not only to protect participants from harm but also to protect other stakeholders. Utility is not the sole justification for paternalistic research policies, since other considerations, such as justice and respect for individual rights/autonomy, must also be taken into account. (shrink)

Paternalism in the medical care of children is appropriate and ethically justifiable. However, dilemmatic disagreement by paternalistic agents as to which clinical choice is in the child's best interest may occur because of the underlying conflict between two rival standards for the moral value of life: longevity versus quality. Neither standard is unreasonable. Either could be the basis for choice of medical care by the parents or by the pediatrician. Having the child choose between options disputed by his parents (...) and the pediatrician is unlikely to resolve their conflict. Exercise of informed consent by the adolescent requires agreement by his parents to relinquish their paternalistic veto. The probable best-interest choice by the child when he has matured could be reasonably made from either standard. Therefore, the longevity/quality of life question ought not ordinarily to be foreclosed by paternalistic authority which opts for one standard to the exclusion of the other. Medical interventions, paternalistically determined, are justified in the face of deteriorating quality, but only as long as the interventions themselves do not cause deterioration. Application of this limitation of paternalism to the zone of agreement between the rival life standards is made to clinical case examples. Multiple extrinsic criteria may measure the quality of life. Three quality factors, sensation of pain, capacity to communicate and physical functioning are considered. The extent of the zone of agreement between the two life standards varies because quality of life is a relative good, contingent both upon which extrinsic criteria are selected to assess it and upon the priorities which are set among these criteria. (shrink)

What I wish to do in this paper is to look at a part of John Stuart Mill's ‘one very simple principle’ for determining the limits of state intervention. This principle is, you will remember, that ‘the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.’.

In The Community of Advantage, Robert Sugden reconstructs and defends an account of the liberal tradition in normative economics in the light of the findings of Behavioural Economics. In...

:Contemporary global governance is organized around an odd pairing: care and control. On the one hand, much of global governance is designed to reduce human suffering and improve human flourishing, with the important caveat that individuals should be allowed to decide for themselves how they want to live their lives. On the other hand, these global practices of care are also entangled with acts of control. Peacebuilding, public health, emergency aid, human rights, and development are expressions of this tension between (...) care and control. There is a concept that captures this tension: paternalism. Drawing on our moral intuitions, I argue that paternalism is the attempt by one actor to substitute his judgment for another actor's on the grounds that such an imposition will improve the welfare of the target actor. After discussing and defending this definition, I note how our unease with paternalism seems to grow as we scale up from the interpersonal to the international, which I argue owes to the evaporation of community and equality. After exploring the implications of this definition and distinguishing it from other forms of intervention, I consider how different elements of paternalism combine to generate different configurations. Specifically, I point to five dimensions that are most relevant for examining the paternalism found in contemporary global and humanitarian governance: the tools used to restrict another actor’s liberty ; the scope of the interference ; the purpose of the intervention ; the source of the paternalizer’s confidence ; and the mechanisms of accountability. These different elements often correlate historically, suggestive of two ideal types of global paternalism: strong and weak. Contemporary global and humanitarian governance is largely the weak variety: force is severely proscribed, interference is relatively restricted, the paternalizer’s confidence has epistemic roots, and accountability to local populations remains a noble but rarely practiced goal. I further speculate that a major reason for this difference is the effects of liberalism and rationalization. I use this taxonomy to suggest how two different global efforts to improve the lives of those peoples living in what were perceived to be unstable and illiberal territories — the civilizing missions of the nineteenth century and the peacebuilding operations of the post-Cold War period — exhibited different kinds of paternalism. I conclude by reflecting on the ethics of international paternalism. (shrink)

The paper presents an evaluation of the paternalistic model of HRM. The analysis reveals that this conception of the employment relationship is deeply flawed and does not provide a morally acceptable approach towards responsible citizens in a democratic society. Moreover, where the employment relationship is based upon managerial hegemony and secrecy, the danger is that this can become institutionalized as a corporate morality that brings about the unintended consequences of moral indifference and unjust conduct towards employees and other stakeholders. (...) The conclusion of this evaluation is that a wise management will try to open up its decision‐making processes and seek the participation of a wide range of stakeholders in the determination of the economic and social purpose of the company. There is another option: the employment relationship can be informed by a communitarian perspective, which aims to strike a balance between the economic interests of employers and employees, and the need for justice to foster mutual cooperation in the pursuit of a common purpose. This conception of the employment relationship will be outlined here as HRM in the ‘community of purpose’. (shrink)

Schonsheck attacks views which seek to justify the majority of citizens of a society passing legislation that is designed to serve the purpose of preventing their own first order preferences from changing over time (or being corrupted). The issue that I think is more important is a related one, but not precisely the same. It is not whether it is morally permissible for the majority of members of a society to pass legislation designed to prevent their own individual preferences from (...) changing over time, but whether it is morally permissible for them to pass legislation for the sake of preventing the community's preferences from changing over time. As some people mature and acquire preferences and others die, no individual's already-formed preferences have to change for the community's preferences to change. The arguments concerning these two issues are the same, or at least similar, but putting the matter the way I do, raises the question of influencing the preferences of children. I argue that there is nothing intrinsically wrong with a community's doing this and that Schonsheck's arguments to the contrary either are not convincing, or apply in some cases but not in others. (shrink)

Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities.

Throughout this essay, I will consider an argument frequently used to justify paternalistic behavior toward a specific class of persons: illiterate people. The argument states that illiterate people are uneducated, lack information and understanding, and are thus unable to make decisions. Therefore, it is argued, paternalism in their case is justified. The conclusion is that illiterate persons cannot be autonomous. The justification for this view is based on an a priori attitude: since it is impossible to communicate, physicians should (...) decide which kind of treatment the illiterate patient should receive. This argument is frequently used even though its proponents may not be aware of its implications. Given the importance and uncritical acceptance this argument has in Argentina, and also in other Latin American countries, I think it is relevant to analyze carefully what it means. I propose a thorough analysis of this argument, of its implications and an evaluation of whether it is acceptable. (shrink)

This article discusses the relationship between the ideal of autonomous preference formation and the danger of paternalism in deliberative democratic theory. It argues that the aim of autonomous preference formation can and should be decoupled from a justification of paternalistic state action aimed at reshaping citizens’ preferences. The problem of non autonomous preference formation is rooted in the communication structure in which each and every one forms her preferences and hence cannot be solved by some paternalistically judging on (...) others’ behalf. The argument is based on a new formulation of the deliberative democratic ideal, which emphasizes and clarifies the multiple dimensions of freedom it incorporates. (shrink)

The Australian Productivity Commission and a Joint Select Committee on Gambling Reform have recommended implementation of a mandatory pre-commitment system for electronic gambling. Organizations associated with the gambling industry have protested that such interventions reduce individual rights, and will cause a reduction in revenue which will cost jobs and reduce gaming venue support for local communities. This article is not concerned with the design details or the evidence base of the proposed scheme, but rather with the fundamental criticism that a (...) mandatory pre-commitment policy is an unacceptable interference with the liberty of the individual, and of organizations. It is argued that the concept of paternalism is a useful lens with which to study the interactions between business and society on this issue. It is contended that the benefits of a pre-commitment system to problem gamblers and society are socially and economically significant, and the cost to recreational gamblers, particularly the cost in terms of interference with the liberty of the individual, is minimal. Pre-commitment also requires gambling businesses to act in a more socially responsible manner. It is concluded that the proposed legislation constitutes a paternalistic intervention by government on the interaction between business and society, and that this is justified. (shrink)

The purpose of this empirical study is to investigate the effect of paternalistic leadership (PL) on ethical climate and the moderating role of trust in leader. Convenience sampling is used as a sampling procedure and the data were obtained from 227 Turkish employees. The findings indicated that PL had some effect on ethical climate. Furthermore, partial support was found for the moderating effect of trust in leader on the relationship between PL and ethical climate. The results of the study (...) showed the importance of PL on employees in following company rules and procedures and showing a sense of responsibility and care to customers, community, and others in the organization. (shrink)

Medical communication in Western-oriented countries is dominated by concepts of shared decision-making and patient autonomy. In interactions with Roma patients, these behavioral patterns rarely seem to be achieved because the culture and ethnicity have often been shown as barriers in establishing an effective and satisfying doctor–patient relationship. The study aims to explore the Roma’s beliefs and experiences related to autonomy and decision-making process in the case of a disease with poor prognosis. Forty-eight Roma people from two Romanian counties participated (...) in semi-structured interviews, conducted by a research team from the University of Medicine and Pharmacy of Iasi. Participants were recruited among the chronically ill patients and caregivers. The Roma community opposes informing the terminal patients about their condition, the “silence conspiracy” being widely practiced. The family fully undertakes the right of decision making, thus minimizing the patient’s autonomy. We identified ethical dilemmas concerning autonomy, lack of patients’ real decision-making power, and paternalistic attitudes exerted firstly by the family and, on demand, by the physician. Instead, the Roma patient benefits from a very active support network, being accompanied at the hospital by numerous relatives. The patient’s right to make autonomous decisions promoted in the Western countries and stipulated by the Romanian law has diminished value in the Roma community. For the Roma, the understanding of dignity is not simply individual and personal, but it is closely related to their cultural particularities. Ignoring their cultural values could create conflicts between healthcare providers and community. (shrink)

The dominant language of politics in the United States has been political individualism, with minimal restrictions on property and personal, voluntary conduct. But there are second languages of community that stress cooperation and group action. These second languages include the constitutional tradition for public health. Public health offers a community justification for paternalistic measures that, for example, discourage smoking or require seatbelts.

This article explores the media representation of Muslims using critical discourse analysis. It emphasises the discursive construction of governmental paternalism that forms the dominant ideological disposition of China Daily’s coverage. The results reveal how Chinese official English newspapers facilitate the government’s dissemination of paternalistic discourse in the news of a large population of Chinese Muslims over the period. The investigation combines topic modelling with topos analysis to identify topics and topoi and to exhibit the ideology through the corpus compiled (...) with CD’s news about Chinese Muslims. Our findings both uncover the extent to which CD is used to promote paternalistic discourse by topic and reveal how paternalism is constructed by topoi. CD can be seen to strongly legitimise the paternalistic framework corresponding with the government’s promotion of social development and security in the region. Reciprocally, most Chinese Muslims are portrayed as obedient and dependent Chinese citizens who benefit from the government’s intervention. (shrink)

In this article we argue that the emergence of a new form of organization – community enterprise – provides an alternative mechanism for corporations to behave in socially responsible ways. Community enterprises are distinguished from other third sector organisations by their generation of income through trading, rather than philanthropy and/or government subsidy, to finance their social goals. They also include democratic governance structures which allow members of the community or constituency they serve to participate in the management of the organisation. (...) Partnerships between corporations and community enterprises therefore raise the possibility of corporations moving beyond philanthropic donations toward a more sustainable form of intervention involving long-term commitments to communities. At the same time they change substantively the nature of any collaboration by allowing relationships to proceed on the basis of mutual advantage, thereby broadening their appeal and scope. In doing so, partnerships build capacity and enfranchise communities in a way that avoids the paternalism that has traditionally characterised relationships between corporations and voluntary sector organisations. Power relations are transformed because partners are seen as sources of valuable assets, knowledge and expertise, rather than recipients of patronage or charity. (shrink)

Mill’s proscription that ‘the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others’ has become almost axiomatic in bioethics. 1 Bolstered by the rise of patient autonomy during the mid-20th century, Millian conceptions of freedom have become so embedded in bioethical theory, that attempts to justify paternalism have typically involved making one of two claims. Either, they have involved refuting the significance of autonomy as (...) an ethical principle, and questioning whether it should always be taken to outweigh other ethical principles. Or, they have sought to cast doubt on the autonomous quality of specific decisions, challenging them as non-autonomous in some important way. Both approaches are readily apparent in discussions about the moral authority of advance directives, where people have questioned both whether precedent autonomy should always outweigh the person’s current best... (shrink)

From a psychological standpoint, communicating a severe diagnosis entails more than just naming a disease, it is a complex process with a number of stages: finding out what the patient already knows about the illness (some of which might be wrong, and thus psychologically detrimental), informing the patient while answering any questions (about the illness itself, the treatment, prognosis, recovery period, etc.) and last but not least, providing a minimum of psychological support depending on the patient’s reaction. Romanian law regarding (...) doctor-patient relationship and communication is modeled on the Anglo-Saxon model centered on patient autonomy and direct communication with the latter if the patient desires to know the truth about his condition. If this is not the case, the patient can name a proxy for doctor-patient communication. There are three legal documents that clarify these aspects: Law of Patient Rights, Medical Association’s Ethics Code and the Health Reform Law. The first two are conflicting on several aspects that we will discuss in this paper. The few studies on doctor-patient communication published in Romania reveal that there is no unitary methodology in this field. The doctors attest that often times the patient’s family, when faced with severe illness turn to the traditional model of communication, i.e. they desire to know the severe diagnosis first and pressure the physician to hide the truth form the patient, contrary to the letter of the law. The aim of this paper is to discuss the issue of communicating severe diagnosis in nowadays Romania in a very complex context: 1. The model of doctor-patient relationship and communication has changed after communist era (from paternalistic to partenerial); 2. Conflicting and missing issues in laws; 3. Laws based on patient’s autonomy principle in a traditional society based on another model of taking care (the patient is part of a family nucleus and the family wants to interfere into the medical communication process). Communication has only recently entered the curriculum of some medical schools in Romania. The doctors questioned as part of a study reveal that they‘ve learned to communicate a severe diagnosis by trial and error. This being said we recommend the inception of practical doctor-patient communication courses that could lead to improving doctor-patient relationships, communication of the diagnosis being their foundations. (shrink)

The COVID-19 pandemic has highlighted the difficult task of balancing access to misinformation with respect for patient decision-making. Due to its innate antagonism, the paradigm of “physician paternalism” versus “patient autonomy” may not adequately capture the clinical relationship. The authors hypothesized that most patients would, in fact, prefer significant physician input as opposed to unopinionated information when making medical decisions. There is a lack of empirical data corroborating this in the United States. To that end, a survey was distributed to (...) 650 individuals through Amazon Mechanical Turk, of which 499 responses met pre-determined quality criteria. Most respondents believed their doctor's insight would be better than their own if injured or gravely ill. When asked to affirm preferences separately, a significantly higher proportion of respondents preferred guidance from their doctor when making medical decisions compared to being presented with unopinionated information ( p < 0.001). Encouragingly, 93.1% believed that the doctor's primary goal was their health. When asked directly to compare physician guidance to unopinionated information, 69.1% respondents stated they would prefer physician guidance. We found a consistent association between educational/economic background and affirmative responses ( p < 0.001), suggesting particular attention should be paid to patients that are disadvantaged with respect to these demographic factors. The belief in a shared goal, and a consistent preference for physician input, suggests that patients endorse a more collaborative view of the clinical dynamic than is suggested by the paternalism-autonomy paradigm. This pilot study suggests physicians should not be afraid to communicate conviction with regard to treatment decisions. (shrink)

This article analyses the extent to which expert authorities have basic communicative obligations to be open, honest, and transparent, with a view to shaping strategies of public engagement with such authorities. This article is in part a response to epistemic paternalists such as Stephen John, who argue that the communicative obligations of expert authorities, such as scientists, permit the use of lying, or lack of openness and transparency, as a means of sustaining public trust in scientific authority. In this article, (...) I elucidate John’s position and reject it. I argue that expert authorities have strong communicative obligations to be open, honest, and transparent, which are grounded in the insight that such authorities hold positions of public trust. After demonstrating how this insight undermines John’s position, I conclude the article by considering the implications regarding public engagement with expert authorities. (shrink)

Community health workers (CHW) are the backbone of the public health system in developing countries. Little is known about the practice of ethics and professionalism in their work. This study was conducted to explore the experiential wisdom of ethics and professionalism among CHWs in Tamil Nadu. We conducted a qualitative study among 125 CHWs in six districts of Tamil Nadu. We found that the CHWs went beyond the call of their duty to do good to the community. Their conceptualization of (...) autonomy ranged from shared to full paternalistic decision making. The CHWs were sensitive to issues of privacy and confidentiality, but the discussion on these topics were limited. They reflected the societal norms of gender, class, and caste hierarchies in their work. They had to work amidst difficult power struggles and had their own innovative strategies to subvert power. In conclusion, there is a need for framing a code of ethics and professionalism for CHWs and training in ethics and professionalism for them to help them effectively deliberate on ethical issues. (shrink)

Addressing the topic of the phenomenon of libertarian paternalism is substantiated by modern problems in the field of settling power relations with society and the individual in a crisis society. In the XXI century, civilized humanity has moved to develop the latest principles of anthropological development. We mean the newest directions of personality development in the system of self-organization as the foundation of building a civil legal social society, in which the problem of free choice of personality in social action (...) becomes crucial. Paternalism of a totalitarian nature has «come into circulation», and modern global society – information and knowledge, encourages the social sciences to find «soft means of control and management of these processes. In the early 2000s, the creators of libertarian paternalism, C. Sunstein and R. Thaler, developed the «push» theory. Its essence is to develop a methodology for proper economic behavior of the individual in the direction of optimal volitional choice. The state and private structures, on the basis of these developments, help individuals to orient themselves in the same organized direction, which harms harm to themselves as consumers of social goods, and encourages others to do the same. This is paternalism, which varies in various forms –from «hard» to «soft». Our study aims to show the socio-philosophical aspects, which fully reveal the essence of this socio-social phenomenon. This is the eternal concept of philosophy –«freedom», «will», which in our direction relies on the modern socio-economic context. For Ukraine, this is a matter of transformation of values, economic interests, in terms of joining the world community. This is the question of educating the individual of a new civilization, in which its self-organization is crucial. Ukrainian philosophy has significant experience in the field of socio-anthropology, socio-ethics, bio-ethics, starting from the school of VI Shikaruka and her followers. Now this experience is developing in the stream of meta-anthropology, methodological principles of individual life in a crisis society (V.P. Andrushchenko, N.V. Khamitov, S.A. Krylova, V.G. Kremen, S.I. Pirozhkov and leading experts, humanities). However, science must be critical of this concept, in order to further study it and understand the possibilities of its implementation in management practice. (shrink)

Before sailing past the sirens' “flowery meadow,” Ulysses instructed his sailors to lash him to the mast so that he would not succumb to the siren's singing. His advance directive demonstrated that he valued his dispositional or long-term autonomy over his unquestioned right to make decisions. He also indicated to his oarsmen that he understood the nature of temptation and his inability to resist it. Ideas of autonomy and sexual choice are central to this discussion of new AIDS treatments, especially (...) the trials of preventative vaccines. Questions arise over the rights of individuals and the extent that these should be limited by concerns of the gay community. Should the gay community intervene in the risky decisions of individuals if no explicit advance directive exists? If so, how do they justify their paternalism? Could their aims not be better served through strengthening the individual dispositional autonomy of trial participants rather than making specific claims about the common good? (shrink)

In this paper we argue that the responsibility for systematic community-based preventive medicine should not be made part of the role of the general practitioner (GP). Preventive medicine cannot be shown to be more effective than curative or supportive medicine. Therefore, the allocation of the large amount of general practice staff time and resources required for systematic preventive medicine should not come at the expense of the care of the sick and the suffering. The traditional healing role of the GP (...) requires a cooperative patient-centred approach, whereas systematic preventive medicine is driven by rigid pre-set protocols and is intrinsically paternalistic. Trying to merge the two approaches is detrimental to the doctor-patient relationship. Furthermore, a number of potential pitfalls are identified that may be encountered in the implementation of preventive medicine programmes in general practice: interference with the course of the consultation; inadequate explanation and consent; distortion of practice priorities as reflected in quality indicators; temptation to record inaccurate data; conflict of interests where the doctor is rewarded for performance; patient blaming; exacerbation of the health gap. We suggest that a more justifiable strategy would be for GPs to identify patients at high risk and offer them specific preventive advice when the opportunity presents itself and at a time when the patient is likely to be most amenable to cooperate. Opportunistic health promotion offers higher expectations of benefit, as well as a more equitable allocation of the risks associated with preventive medicine, than a systematic community-based approach. (shrink)

Critical analyses of the audit profession have become more common in recent years. Many of these analyses focus on the entire audit profession in developing their criticisms and concerns. In this paper, the scope of analysis is narrowed to examine in depth the auditing profession's use of the concepts of reasonable assurance and materiality in audit performance and audit communications. Reasonable assurance and materiality are the terms that auditors use to describe the scope of their responsibility to the public. Similarly, (...) reasonable assurance and materiality are the key determinants of audit effort. An overview of official guidance, practitioner reports, and academic research reveals that these two key concepts are not well specified nor are they consistently applied in audit practice. These findings are evaluated from two competing perspectives on professions – the traditional, functionalist perspective and the critical theorists' perspective. Evaluation from the latter perspective leads to a conclusion that the profession's use of these key terms to guide practice and communication leaves the profession open to charges of mystification and unjustified paternalism. (shrink)

Do states have a right to exclude prospective immigrants as they see fit? According to statists the answer is a qualified yes. For these authors, self-determining political communities have a prima facie right to exclude, which can be overridden by the claims of vulnerable groups such as refugees and children born in the state’s territory. However, there is a concern in the literature that statists have not yet developed a theory that can protect children born in the territory from being (...) excluded from the political community. For if the self-determining political community has the right to decide who should form the self in the first place, then that right should count against both newcomers by immigration and newcomers by birth. Or so the concern goes. In this essay, I defend statism against this line of criticism and provide a liberal justification for the inclusion of children born within the state’s borders. My account leads to some surprising implication for citizenship law, as well as immigration arrangements in the area of asylum and unauthorized immigration. (shrink)

This paper discusses two paradigms of risk communication that guide strategies for communicating food safety issues. Built on the principles of social utility and paternalism, the first paradigm heavily relies on science and technical experts to determine food safety regulations and policies. Risk communication, in this context, is a unidirectional process by which experts from the industry or government regulatory agencies inform or alert potentially affected publics about the hazards they face and the protective actions they can take. (...) However, public trust and confidence in government and industry have considerably declined. Experts are being questioned about the objectivity of their assessments of risks. Policy makers are being challenged on such risk management decisions as tolerance guidelines, food labeling laws, and emergency warning systems. Concomitantly, some segments of the public, especially consumer advocates and environmental groups, are demanding increased input into the decision making process as they call for the recognition of lay perceptions and interpretations of risk as a legitimate counterpart to technically-assessed risk. Hence, instead of the linear, persuasion-oriented communication process, there are evolving efforts to shape risk communication into a more dialogical, interactive, and democratic exchange of information among different stakeholders (i.e., technical experts, government policy makers, industry, interest groups, and the general public). Reflecting a more Jeffersonian approach, this second paradigm argues that decisions about food safety are so complex and multi-dimensional that they must not be left to experts alone.However, both paradigms present ethical dilemmas. Determining the risks and relative safety of foods is not a totally objective and concise process. Since it involves social, economic, political, and personal values, how can the public not be involved in the exchange of ideas and information concerning food risks and safety? On the other hand, can we afford to let public opinion govern decisions pertaining to food risks and safety without consideration for the merits of scientific risk assessment? This paper raises questions regarding some assumptions of these two risk communication paradigms, and explores and discusses some of the salient ethical questions inherent in each framework. (shrink)

In a striking formulation, Ophélie Siméon describes her study as “an intellectual biography through a sense of place”. The subject of the intellectual biography is Robert Owen, the enlightened manufacturer turned universal reformer—and the father of British socialism. The place is the New Lanark Mills, the idyllic Clydeside factory village Owen superintended from 1800 to 1825. Owen’s spectacular entrepreneurial and humanitarian successes as a paternalistic manager served as the springboard for his subsequent career as a radical activist and socialist (...) pioneer. Concomitantly, the prosperity and happiness of the New Lanark community during his tenure provided “a founding myth of British socialism”.... (shrink)

Doctor–patient communication is a crucial component in any therapeutic encounter. Physicians use words to formulate diagnoses and prognoses, to disclose the risks and benefits of medical interventions, and to explain why, how, and when a therapy will be administered to a patient. Likewise, patients communicate to describe their symptoms, to make sense of their conditions, to report side effects, to explore other therapeutic options, and to share their feelings. Throughout the history of medicine, the ethics of the doctor–patient (...) class='Hi'>communication has been traditionally grounded on considerations of paternalistic beneficence and nonmaleficence. In this respect, it was no different from the ethics regulating.. (shrink)

The doctor's use of deception in appropriate circumstances has commonly been considered a necessity of the medical art. Resistance to full and frank communication is typical of many traditionally Catholic countries, and particularly of Italy, a western country where Catholicism remains particularly influential. The Catholic teaching on truth and lies, and the problem of telling the truth to a severely ill patient is discussed. It is suggested that the contemporary Catholic model of gradually telling a terminal patient the truth, (...) which looks reasonable and feasible in theory, is rarely followed in practice, as in the majority of cases the truth is not told tout court. Problems stem from the way in which medicine is currently practiced in Italy; from the synergism between Catholicism and the medical tradition's grounded paternalism; and from the ambiguity of the term ?hope?. Catholic ethics in fact recommends that the truth must be told without destroying hope, but the Catholic meaning of ?hope? is very different from its meaning in current language. (shrink)

OBJECTIVES: To study some ethical problems created by accession of a previously nomadic and traditional society to modern invasive medicine, by assessment of physicians' attitudes towards sharing information and decision-making with patients in the setting of a serious illness. DESIGN: Self-completion questionnaire administered in 1993. SETTING: Riyadh, Jeddah, and Buraidah, three of the largest cities in Saudi Arabia. SURVEY SAMPLE: Senior and junior physicians from departments of internal medicine and critical care in six hospitals in the above cities. RESULTS: A (...) total of 249 physicians participated in the study. Less than half indicated they provided information on diagnosis and prognosis of serious illnesses all the time. Physicians who were more senior and those who spoke Arabic fared better than other groups. The majority preferred to discuss information with close relatives rather than patients, even when the patients were mentally competent. Most of the physicians felt patients had the right to refuse a specific treatment modality, and 68% denied patients the right to demand such a treatment if considered futile. Further analysis showed that physicians' attitudes varied along a spectrum from passive to paternalistic with the largest group in a balanced position. CONCLUSIONS: In traditional societies where physicians are regarded as figures of authority and family ties are important, there is a considerable shift of access to information and decision-making from patients to their physicians and relatives in a manner that threatens patients' autonomy. Ethical principles, wider availability of invasive medical technology and a rise in public awareness dictate an attitude change. (shrink)

From an ethical point of view, shared decision-making is preferable to either physician paternalism or patient sovereignty. The traditional model of doctor-patient communication is too directive and too unconcerned with the patient's values to support truly shared decision-making. The traditional distinction between rhetoric and sophistic can provide the basis for a new model of mutual persuasion that does not limit communication to information, and that avoids the spectre of manipulation.

Health care decision making has changed profoundly during the past several decades. Advances in scientific knowledge, technology, and professional skill enable medical providers to extend and enhance life by increasing the ability to cure disease, manage disability, and palliate suffering. Ironically, the same interventions can prolong painful existence and protract the dying process. Recognizing that medical interventions, especially lifesustaining measures, are not always medically appropriate or even desired by a patient or family, health care professionals endeavor to determine who should (...) make health care decisions and according to what standards. The importance that Western culture places on individual rights and self-determination is reflected in the growing advocacy for patient autonomy and the discrediting of physician paternalism. However, the question of autonomy becomes more complex when patients lack the capacity to decide for themselves.Advance directives represent one response to the dilemma of decision making for incapacitated patients. The original advance directive, the living will, is a written list of instructions reflecting the individual's wishes about care, usually at the end of life. (shrink)