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AUTONOMY, PATERNALISM, AND THEIR MEDICAL RELEVANCY
By
Kendall Nicosia-Rusin
Honors Essay
Philosophy
University of North Carolina
March 30, 2014
Table of Contents
I.
Introduction
3
II.
Theories of Autonomy
6
III.
Kantian Autonomy
10
IV.
The Concept of Paternalism
14
V.
Justification of Paternalism
16
VI.
Divergence from Past Theories
19
VII.
Case Studies
26
VIII.
Conclusion
32
IX.
References
34
2
I. Introduction
Consider Robert, a 27 year-old who is admitted to a Chicago emergency room with
cellulitis in his left leg. His physician discovers that he has been homeless for quite a while and
has a history of intravenous drug use. He presents with a borderline-low white blood cell count,
and the physician encourages him to test for HIV. Robert – lacking any additional symptoms
such as weight loss, lymphadenopathy, and HIV-related illnesses – refuses the test. This is a
very straightforward scenario that could happen anywhere, where a patient decides not to pursue
certain screening and testing options. It is within the patient’s right to control what foreign
objects enter his body or what is taken from it. In Illinois, however, physicians are permitted to
test patients for HIV without their knowledge or consent. The motives for this law may be based
purely in public health: the more people that are screened and aware of their infected status, the
fewer people that are carelessly or unknowingly infected. In fact, in trying to justify this law, we
can easily appeal to a utilitarian rationale. What is the comparable worth of the one patient’s
right to consent to healthcare when the life and health of a larger number of individuals is at
stake?
It is also rather easy to remove the public health lens when considering Robert. What if
the physician wanted to test Robert for the benefit of Robert? If he truly was HIV positive, he
would need to start a strict drug regimen and make lifestyle changes to accommodate his
infection. The difference between getting tested and not may be the difference between Robert
dying in five to ten years and living for forty more. Therefore, the physician’s decision to test
Robert is in Robert’s best interest – all motives for action reflect concern for the patient. Testing
Robert against his will would align with a common conception of justifiable paternalism – a
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coercive action for the benefit of the actor, in this case, the patient.1 In this case, the fact that
such intervention is legalized makes the physician’s decision quite easy and defensible.
However, what of other cases where no law exists to predetermine a physician’s actions? How
do we know when paternalism is truly justified?
While Robert’s case seems to be one where we intuitively agree with the choice of the
paternalistic physician, it still raises a concern about what the patient is losing in this
relationship. As stated previously, patients should have the right to determine how their body is
prodded and manipulated. A common label for this characteristic is autonomy, often seen as a
nearly inviolable right which I will show is wrong. If we agree with the physician’s decision
regarding Robert, then we need to be able to explain why Robert’s autonomy may be overlooked
or ignored. Further, we may also find that the importance of autonomy is such that paternalism
is never justified, even if we intuitively believe it may be so.
We may also note that due to the public health motive of the example of Robert, this is
not a case of pure paternalism. The problem with this is that the justification for action may
actually be swayed by characteristics that are unrelated to paternalism, preventing us from
developing an analysis of valid and invalid paternalistic actions. Instead, consider the case of
Rose, an 82-year old grandmother who has been hospitalized with severe heart and kidney
disease. Given the severity of her illness and her age, it is very likely that she will die soon.
While she is frail, she is still conscious and lucid, and she expresses an interest in understanding
her medical condition. Her son, Peter, has told the physician that he would rather his mother just
slip away without knowing any upsetting information that would cause her to worry. The
paternalistic action, therefore, would be to go against the patient’s wish to know her medical
1
Feinberg, Joel. “Legal Paternalism.” Canadian Journal of Philosophy. Vol. 1, Issue 1. 1971. pp.105-124.
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information and hide her bleak prognosis with the understanding that this knowledge would
create misery and anxiety for her. Intuitively, we can say that this action is not justified. When a
patient wants to know information regarding her health and the physician possesses this
information, the patient has a right to disclosure. If the physician had a sense from the patient
that she really didn’t want to know the information, that may change the scenario. However, in
this instance, the decision is straightforward. Why can the physician act to coerce Robert but not
Rose? Why does it seem like Rose’s autonomy demands more respect than Robert’s?
Given the practical nature of these problems – that they are a common occurrence in
medicine – it is imperative that we have a reliable method of approaching the ethical dilemma.
Whether or not physicians act paternalistically or respect a patient’s autonomy depends on what
those concepts mean and what they imply. This paper is dedicated to this analysis. After
examining and criticizing some familiar conceptions of autonomy and paternalism, I will suggest
that we return to the Kantian root of autonomy, the idea that autonomy is an essential aspect of
moral agency. Since Kant’s definition of autonomy is heavily theoretical and impractical, I will
suggest a new way to define autonomy: the rational setting of ends. Autonomy is frequently
used interchangeably with liberty, but these, I argue, are two very different concepts. Liberty or
freedom is about unrestrained action and choice whereas autonomous choices are constrained by
rationality. Liberty may also be a claim-based right whereas autonomy never is a right. My
definition of autonomy takes from Kant the idea that autonomy is status as a moral agent. It
would be misleading to discuss a right to autonomy because to have rights, we must be moral
agents, but autonomy is an essential condition of being a moral agent. Therefore, the order of
attainment is first moral agency and autonomy and second, moral rights. I will then find that
paternalism may be justified when it violates liberty but is not justified when it violates
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autonomy. Finally, I apply these concepts to more complex medical cases to determine when
physicians are justified in acting paternalistically.
II. Theories of Autonomy
We use the word autonomy loosely, and with it, we colloquially connote a certain ideal
that some consider to be a right. Never are we criticized for acting autonomously or claiming
our autonomy. Possessing this characteristic is seen as an indication of maturity, higher
cognition, and responsibility for ourselves. If we are going to support and promote a behavioral
characteristic or a property of morality, we must first fully understand the proper, not common,
meaning of the word. Let’s consider the most basic idea of autonomy – the ability to make
decisions about issues that affect one’s own life without interference from others. For instance, I
may choose to exercise regularly and monitor my daily nutritional intake. This is a lifestyle
choice I make independently, based on my desire to maintain my health and generally increase
the quality of my life. This sort of independent choice that will affect the chooser is one we want
to endorse. The interference of another who might say that I cannot pursue this lifestyle because
I must do my fair share to consume a surplus of calories or who would reserve healthful
resources for those with more need to lose weight than I is repellent. The choice affects the
quality of my life and if I am not allowed to pursue improving the quality of my life, both in
hedonistic and deeply meaningful non-hedonistic ways, then the incentive to make efforts in life
and the value of life is depleted.
Does this mean that we can make decisions about traffic lights, sales at stores, and artwork
hung in waiting rooms? Choices about these issues do affect our lives, insofar as our lives are
shaped by our interactions with external forces; however, the effect of these external settings on
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our lives is seemingly superficial or recognizable as uncontrollable by the individual. My life
would be better if on my commute to work, every stoplight I encountered was green. To expect
to be able to choose the timing of the stoplight to accommodate the needs of my routine is absurd
because then everyone would try to lay claim to control of stoplights and all preferred timings
would conflict to the point of chaos. Consider the interior design of waiting rooms. I may be in
an extreme minority of people who care deeply about what prints of paintings are chosen for
display. I need not experience the displeasure of modern abstraction if I were allowed to hang a
couple of Monets and Cassatts. While this may lead to a more pleasurable time in a waiting
room, this change in an external setting is very insignificant. The effects of this decision do not
permeate my life beyond the moment I am in the waiting room. This superficiality of ‘an issue
affecting one’s life’ in this instance indicates that autonomy needs some gravitas.
Perhaps the previously suggested definition should be clarified and reread as ‘the ability to
make decisions about issues that deeply affect one’s own life.’ This still lacks the ability to fully
encompass the meaning of autonomy. If every day I depend on others to choose my meals and
cook for me, I am clearly lacking a kind of autonomy; yet cuisine does not have a profound
effect on my life. One difficulty in defining autonomy is finding the threshold. On the scale of
unimportant to life-changing decisions, where do we want to allow autonomy’s jurisdiction?
Additionally, the relevance of this example changes depending on the context of the situation. If
I am physically disabled to the point that I cannot prepare my own food or if I have such extreme
dietary restrictions that I require a nutritionist to oversee my diet, then it would be odd to say that
this indicates a lack of autonomy. Similarly, if I choose to fly but cannot, this is no fault of
autonomy but of physical limitation. Therefore autonomy must also reflect physical ability.
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We seem to be straying too far from our understanding of this concept, and I suggest that we
return to the original etymology of autonomy: self-governing. Self-governance is about
controlling our own lives and the personal choices we must make, both superficial and profound.
External issues are not at play – my inability to control the traffic that makes me late to work is
not an infringement of my autonomy, but a law requiring me to wear my seatbelt may be. This
second instance illustrates a possible violation of my will. Whereas I cannot will the traffic light
to change and accommodate my schedule, I can will myself to wear or not wear a seatbelt. For
now, let’s just continue with the idea that a violation of autonomy is a violation of the
individual’s volition.
What claims do we have to autonomy so defined? Autonomous individuals ought to be free
from certain influences. Since I am an autonomous individual, I have rights to make decisions
about personal matters, and such a right begets a duty of others to not interfere with my exercise
of my autonomy. The formation of their rights is a recognition that individuals ought to employ
their psychological capacities, for prevention or interference of such employment would
diminish essential qualities of individuals, thus devaluing them. We have a right to freedom of
expression; yet, if we were not a social species able to express our complex thought, violation of
this right would not put us in a worse off situation. Nobody accuses one of a violation of free
speech when giving a screaming baby a pacifier. In order to have a right to freedom or liberty,
we must first possess some corresponding relevant psychological capability.
All that has been discussed above captures the common conception of autonomy – a right to
self-governance, a psychological capability that ought to be respected as a capability such that
we are able to exercise the competency. However, considering autonomy as a right seems
erroneous and doesn’t fully encapsulate its value. The kinds of moral rights relevant to our
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discussion are claim-based, meaning that those with rights make claims on others to act in
accordance or not interfere with the right. In essence, claim-rights beget duties. Specific to
autonomy, it makes sense to discuss two rights-based duties: one, a duty to not interfere or
restrict an individual’s autonomy, and the other, a duty to oneself to act autonomously if capable.
I believe it is more instinctive to discuss these two duties than to discuss a right to autonomy.
Perhaps one might say we have a right to not have others interfere with our autonomy – that is to
say, we have a right that others obey their duty to not interfere with out autonomy. This right is
not the same as saying that we have a right to autonomy; instead, this is a right regarding how
others act towards us - that others respect our potential characteristics including autonomy.
Additionally, others’ duties and our own duties with respect to our autonomy do not indicate that
there is a corresponding right. While the existence of a right requires a duty related to it, the
presence of a duty does not necessarily mean there is a right that the duty is respecting. We have
these duties concerning autonomy, we may have a right regarding interference of our autonomy,
but we don’t have a right to autonomy.
Rejecting the concept of autonomy as a right, we are left with the layman’s understanding of
autonomy – self-governance. While this is a wonderfully simple definition, it misses an essential
complexity of this concept. It does not shed light on the value of self-governance nor does it
explain why we don’t find control of young children’s behavior morally troublesome. The
common conceptions of autonomy are too weak to serve us well in our exploration of patient
autonomy. To find the essence of the meaning of contemporary autonomy, we should begin in
its grounding with Kant.
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III. Kantian Autonomy
For Kant, autonomy is an essential part of the will of a rational agent – for one to act morally,
the will must be autonomous. We cannot be bound by moral obligations and duties in Kant’s
sense without autonomy as a property of the will.2 An explanation of Kant’s conception of the
will and its function will help to illustrate the importance of autonomy. As previously
mentioned, the will is the essential feature of an autonomous rational agent. It is the ability to act
on the basis of principles, reason or duties. Thomas Hill, providing an interpretation of Kant,
remarks, “The will is not, as it was for Hobbes, the last and strongest appetite in a deliberation
that causes my body to move, nor is it, as it was for Hume, a peculiar sort of mental event
(‘impression’) that occurs just prior to my acting.”3 It is deliberate choice based on maxims that
marry universal laws with our particular actions.
An autonomous will is free in a negative sense. This means that an individual is able to act
without the choice of action being determined by external physical or psychological forces. An
addict is not negatively free to indulge in the addiction because the addiction dictates the choice
of action. Another aspect of a negatively free will is that it is able to choose actions based on
maxims that are not the individual’s inclination. That is to say, our actions are not motivated
solely by our desires, interests, or prospective happiness. Our actions may be motivated by
reasons or principles that we choose to follow including reasons to act on some desires.
Additionally, an autonomous will is also free in a positive sense. The will cannot be lawless,
and Kant suggests that it is subject to laws of pure practical reason. Willing in this sense is
making choices based on universal maxims of rationality. This may not seem like a freedom at
2
Hill, Thomas. “Kantian Autonomy and Contemporary Ideas of Autonomy.” Oliver Sensen, ed., Kant’s Conception
of Autonomy. Cambridge University Press: 2013. pp. 15-31.
3
Hill p. 19
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first but consider the concept more closely. Laws of pure practical reason are not imposed on
individuals – instead, they are recognized by individuals who set them as their own standards.
The freedom lies in our being subject only to the laws we and other rational beings will for
ourselves and each other. Not only are we free to choose to act, we are also free because we
have set the maxims. Taking all of this into account, Kant considers autonomy as “the property
of making and being subject to laws ‘independently of every property belonging to the objects of
inclination’.”4 So defined, autonomy is about setting and obeying laws that can be promoted by
all rational agents as opposed to personal ideals or goals.
Kantian autonomy retains and strengthens the implied value of commonly conceived
autonomy. If autonomy is part of moral agency and moral agency is the standard to which we
aspire, possessing a characteristic of it – autonomy – betters us as individuals. Kantian
autonomy’s strength is its maturity over the colloquial understanding of autonomy as control of
one’s own actions. Instead autonomy requires rationality (a good choice since we wouldn’t want
to say that a young child is completely autonomous) and recognition of holding oneself to the
same standards one holds everyone else. Through the concepts of negative and positive freedom,
autonomy is no longer lawless – it cannot be solely subject to desire and inclination and it must
work within accepted universal laws.
Nevertheless, the Kantian conception of autonomy is not a practical one. It is abstract and
theoretical, and while it unifies deeper concerns of what an autonomous agent is like, his theory
has no direct implication that can be useful to us in pursuit of understanding autonomy and
paternalism as they are understood in medical ethics.
4
Hill p. 20
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In an effort to define autonomy in a way that captures the concerns of contemporary medical
ethics without leading to theoretical incoherence, I propose that we adopt a neo-Kantian
understanding of autonomy as the ability to set ends for oneself. This definition has a certain
elegance to it that the more colloquial ones lack. Instead of trying to determine which things
count for affecting our lives deeply or attempting to define which states of freedom are those of
enough importance to contrast autonomy with physical liberty or unintentional action, we deal
with one concern – values. Autonomy is about determining and ranking intrinsic goods for
ourselves on a subjective ground.
Meghan, an autonomous 29 year-old, has decided that for her, absence of chronic pain is
more important than prolonging life, but prolonging life is more valuable than avoiding minor
nuisances such as seatbelts. She has come to this prioritization on her own, through selfreflection and consideration of the possible lives that would result from an alternative ranking of
values. On the other hand, Billy, a 5 year-old, lacks the capacity for this sort of prioritization.
He may have certain values, but his expression of them is simply a regurgitation of what his
parents have told him. This fits with our intuitive sense that children are not fully autonomous,
for to have that characteristic, one must understand the concept of values, must be able to reason
through their ranking, and to self-reflect on ingrained values from one’s past.
The ability to set ends is fundamental to being a moral agent. This explains why we find
violations of autonomy so repugnant. First of all, since autonomy is an essential characteristic of
a moral individual, violating autonomy is a violation of the sanctity of the rational individual.
This also clarifies why autonomy is not a right. As stated previously, moral rights are claimbased. Individuals are either autonomous or they are not – they cannot make any claim to
autonomy just as they cannot make a claim to being a moral agent. These properties are inherent
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to the moral agent and cannot be supplied by an exterior force. Autonomy is still very relevant
to moral rights. Making claims requires autonomy since one must know one’s ends and thus
make the required claims to achieve or protect those values. For instance, I as an autonomous
agent have set my values, one of which is the prolongation of my life. Being autonomous
requires rationality; therefore, I cannot value prolongation of my life at all costs nor could I value
the presence of injustice. Such values are irrational as they are destructive to societal constructs
and they promote self-interest at the expense of other individuals and their autonomy. For
instance, I cannot claim the right to the kidney of my mother to save my life to promote my value
of prolonging my life. I express my autonomy when I prioritize the value of my life highly. I
have also prioritized the values of justice and others’ autonomy highly. Taking these other
autonomously set values into consideration, I find that to claim a right to life does not accurately
reflect what I value. Therefore, the right I autonomously claim is the right to not be killed
unjustly. This demonstrates the close interplay of autonomy and rights. Autonomy is the
foundation for the basis of all moral rights because the claims behind the rights derive from the
rational hierarchy of values that is characteristic of autonomous individuals.
Another explanation behind why others falsely claim autonomy as a right may stem from the
fact that a violation of other rights seems to mirror what a violation of autonomy would produce.
If a right not to be deceived could be considered a moral right, then imagine what occurs when
the autonomous individual experiences deceit. False information, manipulation, and
misdirection create a false reality which interferes with rationality. Impaired rationality impacts
autonomous thought and the ability to set ends. It is for this reason that our interest in claimbased rights is due to our interest in preserving our autonomy – these rights assure maintenance
of the conditions we require to set individual values and prioritize. This close relationship, where
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impeded autonomy is a consequence of violated rights, is why we commonly think of autonomy
as a right. It is important to remember that it is, instead, an essential aspect of a moral agent and
imperative in making claim-based rights.
IV. The Concept of Paternalism
On the definition of autonomy as setting one’s own ends, it is easy to see how difficult it is to
find a justification for a violation of this most essential characteristic of a moral agent. Often
associated with a violation of autonomy is the concept of paternalism. As it is commonly
understood, paternalism is a violation of autonomy for the benefit of the violated individual. The
concept is derived from a parental relationship where a parent may restrict what type of foods her
child may eat or force her child to take a nap. The parent does this not for her own benefit. She
does not feel pleasure in controlling her child’s life nor does the child’s diet or nap time affect
her. Instead, her rules and restrictions are constructed for the purpose of helping her child
develop in the best way possible and to ultimately become an autonomous being. True
paternalism should be used only to benefit the individual experiencing coercion.
On the surface of it, paternalism does not seem controversial in the slightest – it does not
involve manipulation of moral agents to be used as instrumental beings. The paternalist acts out
of concern for others’ welfare. However, imagine yourself about to plan a two-week vacation to
Europe, an expense you’ve been saving up for since you first thought it out a couple of years
ago. Just as you are about to book your flight, buy your Eurorail pass, and reserve your villa, a
non-profit group freezes your bank account and informs you that putting that money towards a
retirement plan is a much better investment for you. Assuming you are many years away from
retiring, you would truly resent this override of your decided priorities. At this stage in your life,
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this trip has greater value to you than your financial situation 40 years down the road. This
captures not only the bizarre idea of external others interfering with actions chosen by our
internal thoughts and mindsets but also the high value we place on liberty.
Liberty or freedom is not the same thing as autonomy. Freedom describes being physically
unrestricted – a free person may act however they choose as long as their action does not restrict
the freedom of another. Autonomy on the other hand is not a description of our physical state
but is a characteristic of our moral selves. An individual could be autonomous but unfree or free
but not autonomous. For instance, a convict in prison obviously lacks freedom. He may still be
autonomous because he is still able to set ends for himself, like whether it is more important for
him to have a reduced sentence due to good behavior or whether he values his rank within the
prison system and acts out to show his dominance. Alternatively, anyone could have freedom
and do whatever they desire but if they do not rationally prioritize their values, then they do not
act autonomously.
When it comes to paternalism, both autonomy and freedom may be affected to different
degrees. Consider seatbelt laws. A law requiring all drivers to wear seatbelts is definitely an
infringement of liberty. The range of choice of action is limited to one (realistically two – you
either wear the seatbelt or you don’t – but legally, one). Whether or not this is a violation of
autonomy is another question. If the driver values her life but irrationally favors not wearing a
seatbelt, then forcing her to wear the seatbelt does not violate her autonomy; in fact, it
encourages her to act in ways that align with her autonomously set ends. On the other hand
perhaps it is conceivable that a driver may rationally rank freedom and physical comfort as more
valuable than prolongation of life in that case. Another commonplace example would be a
scenario at a bar. Suppose you and a friend are out and have had a couple of drinks. Your friend
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wants to act impulsively – get in a fight with a stranger, hook up with a casual acquaintance,
drive home while drunk – and you prevent him from doing so. Obviously, you are interfering
with his liberty and restricting his actions; however, his autonomy is untouched. First of all, his
mind is in an altered state, where he is clearly unable to rationally prioritize his values. Second,
you know that tomorrow, he will regret these decisions and their consequences, and so you save
him the pain of that shame and act paternalistically.
These are just a couple of cases of justified paternalism. Unless you are a strident libertarian,
you probably find nothing wrong with the paternalistic action taken here. Obviously not all
cases of paternalism are justified but there are instances where we find worth in paternalistic
action. What is the essence of the action that makes it valid? In both the case of the seatbelt and
the friend at the bar, paternalism involves only a violation of liberty, but in the case of Rose, the
82-year old grandmother who wants to be informed of her medical condition, paternalism would
involve a violation of her autonomy. I propose that the rule of thumb is that a paternalistic
interference with liberty is sometimes justified and a paternalistic interference with autonomy is
never or rarely justified. Whether or not paternalism is justified must then depend on what
aspect of the human experience it is affecting.
V. Justification of Paternalism
The argument for the justification of paternalism cannot rely solely on examples. Why is
autonomy inviolable but liberty not? Autonomy is a fundamental attribute of a moral agent. An
individual is either autonomous or they are not. Autonomy so defined cannot be claimed as a
right because it is a capability and a utilization of rationality; rationality is an essential feature of
autonomy and no right can be claimed to rationality. Similarly, we cannot claim a right to be a
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moral agent – it makes no sense to talk of such a capability as a right. We possess rationality,
consciousness, and self-awareness that allow us to practice morality, but if we weren’t those
things, we wouldn’t claim a right to them. To give an analogy, we possess optic nerves, rods and
cones in our retinas, and accommodating lens, all which contribute to our ability to see. Those
with damaged optic nerves do not talk of a violated right to vision, but instead discuss capability
and impairment. Autonomy is a status of moral agency which is dependent on the existence of
several other mental capabilities of humans. None of these properties could rationally be
claimed as a right.
Unviolated autonomy is essential to moral agency. Arguably, moral agency is the most
inviolable characteristic of any individual. To restrict or prevent full actualization of moral
agency is to prevent an individual from accessing a trait most unique to humans. If a steadfast
rule is never to prevent someone from being a moral agent and if autonomy is essential for moral
agency, then it would follow that autonomy may also never be violated.
Autonomy is also a basis for reciprocal claim-based rights. As the autonomous individual
rationally prioritizes her values and sets her own ends, she claims rights to the means to
achieving these ends. These rights heed respect and attention of other moral agents for
consideration because these rights are derived from an inviolable autonomy. Via the connection
of rights to autonomy and autonomy to moral agency, respect for an individual’s rights is
therefore a way to promote moral agency. Rights to liberty are among the rights connected to
autonomy. In order to meet many different ends, the moral agent requires liberty of action.
Freedom to choose how we act is essential to reflecting how we have ranked the importance of
different values.
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Rights are not set in stone – that is, if you claim a certain right, you are not guaranteed
limitless acknowledgment or fulfillment of the right. First of all, rights are claims made on
others and therefore are dependent on the acceptance of the claim by others to grant the right.
The idea of reciprocal claim-making is key here.5 This means we claim rights with the
understanding that others may claim the same rights, and we are more likely to grant each other
rights with the understanding that the same rights will be granted to us by others. This also
means that if one individual does not respect the rights of others, it is an appropriate response to
limit the offending individual’s rights. For instance, a basic right is the right to not be killed
unjustly. The common response to murderers is to severely restrict their right to liberty. Rights
are not above violation, but such violation must be justified.
Paternalism as an interference with liberty is a prima facie violation of the right. In the case
of the friend at a bar who has had too much to drink, restricting his liberty is justified with the
understanding that he would truly regret his actions once he was sober. This underlying subtext
of paternalism – that the action will truly reflect what the coerced individual values but does not
necessarily want at the moment – is central to the justification of the action. Another way to say
this is that justified paternalism is an effort to restore or protect autonomy. Whether it be
micromanaging a drunk friend in a bar, enforcing a ‘click it or ticket’ law, or restraining an
emotional person from committing suicide, the idea behind each act of paternalism is that
coerced individual’s choices will not result in the truly desired or valued consequence of that
action. Interruption of these non-autonomous choices is justified because paternalism is
promoting the individual’s welfare.
5
Anderson, Elizabeth. “If God Is Dead, Is Everything Permitted?” Philosophers Without Gods: Meditations on
Atheism and the Secular Life. New York: Oxford University Press, 2007. pp. 215-230.
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Paternalism towards liberty is vastly different from paternalism towards autonomy because
the latter reflects a judgment on an individual’s set ends, namely that they have been incorrectly
set. For a system of values that is determined rationally, this is a reflection of autonomy and thus
moral agency. Any attempt to correct the system of values indicates a lack of respect for the
moral agent and is never justified. Therefore, paternalism can either be a violation of autonomy
or liberty for the benefit of the individual whose autonomy or liberty is violated. A violation of
autonomy is never justified, but paternalism with regards to liberty is sometimes justified,
specifically in cases where the violation of liberty reinforces the individual’s autonomy.
VI. Divergence from Past Theories
This concept of paternalism differs from what others have claimed the concept means. For
instance, a popular reading of John Stuart Mill suggests he believed the only justification for
interfering with liberty was to prevent harm to others.6 According to this interpretation, his
philosophy did not even allow for a concept of paternalism because he saw the individual as
having sovereignty over body and mind. His principle of non-interference except to prevent
harm to others is known as the harm principle and only applies to humans with mature faculties.
Mill’s strongest argument for why interference with liberty is wrong is that such interference
may be wrong, i.e. there is a possibility we may cause harm by interfering with liberty and so to
err on the side of caution, we should not interfere. If we are willing to impose our own morality
on someone else, then we best be ready to have someone else’s morality imposed on us. If that
causes concern, then we should just respect liberty and never violate an individual’s right to it.
While Mill’s theory is attractive in its simplicity and its staunch defense of a right to liberty, it
fails in that it does not explain our commonsense reactions to different scenarios. Under Mill’s
6
Mill, John Stuart. On Liberty. 1859. Kitchener: Batoche Books. 2001.
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theory, we should not interrupt our drunk friend at a bar. We shouldn’t hold his car keys for him
and we should let him pick a fight with a stranger. In reality, we would never act this way. Any
theory of paternalism must be able to explain our intuitive actions in relatively black-and-white
scenarios.
Another concept of paternalism is that of legal paternalism: justified coercion by the state to
protect the actor from his action.7 In more extreme cases, interference with liberty is justified on
the grounds of betterment of the actor versus simple prevention of harm. Cases of legal
paternalism imply that the state knows the interests of its citizens better than the citizens know
themselves, giving the state guardianship over those interests in loco parentis. Feinberg
indicates the potential danger of legal paternalism by extending the citizens as children of the
state analogy: after a while, you must treat children more maturely or else they never leave their
child stage. Similarly, citizens without rights necessary to exercise their autonomy8 lose power
of rational judgment and decisive action. However, as stated previously in response to Mill,
Feinberg thinks that to reject paternalism entirely would be to go against commonsense. It
would mean that a person’s own good is never a valid reason to coerce him. It is commonsense
to reject the validity of an individual’s consent to undergo disablement, murder, or slavery.
Under this logic, we should act to prevent anyone from selling themselves into slavery because it
is intuitively against their welfare and lacks any semblance of rationality. Where Mill only
allows for interference when harm to others is involved, Feinberg states that the individual’s
personal good plays a large role in justifying choices for or against certain actions. When
personal good is not promoted, paternalism may be justified.
7
Feinberg, “Legal Paternalism.”
Here, autonomy does not reflect the proposed definition of a rational ability to set one’s ends, but is understood
more loosely.
8
20
Since actions towards oneself can be considered consensual if they are informed and
voluntary, Feinberg finds it important to distinguish the degree of volition involved with action.
A voluntary assumption of risk is equivalent to the Aristotelian deliberate choice. Impulsive or
emotional actions are not chosen – instead, this is acting on desire which is not in accord with the
Kantian idea of autonomy. Voluntary actions are those that come from a place of calmness and
deliberateness, without distractions, emotions, compulsion, and misunderstanding. These
distinctions will be important to consider when examining practical cases of autonomy in
medicine.
To me, misunderstanding seems to be the most interesting consideration related to volition
and the right to liberty. As Feinberg illustrates, the woman who thinks she is sprinkling salt on
her dinner when it is actually arsenic is acting involuntarily.9 Here, Mill would permit
paternalism to protect an individual from her own ignorance, given sufficient evidence that her
misinformed choice differs from her intended choice. Feinberg goes further and says that “on
other occasions a person may need to be protected not from his ignorance but from some other
condition that may render his informed choice substantially less voluntary.”10 In this way,
paternalism is justified for children and the mentally ill. Mill would not allow any individual
lacking the ability to reflect and reason to jeopardize their safety. Feinberg concludes that
paternalistic interference may occur to prevent self-harm when the action is not voluntary or
when the interference may halt the action to allow for establishment of whether or not the action
is truly voluntary.
9
Feinberg, “Legal Paternalism.”
Feinberg p. 117
10
21
This view of paternalism is an easy pill to swallow. It is not a true violation of voluntary
action and is concerned with the individual’s own concern for her well-being. The major
problem is this: how can we determine whether someone has full reflective and reasoning
capacity? If I see someone about to jump off a bridge, I will try to stop them to prevent them
hurting themselves. However, if I personally find suicide to be an irrational decision, no
justification the jumpee gives me will show me that that he has made a rational decision. The
fact that I am moved to interfere with liberty indicates that I already have a preconception of
what is a rational choice and what is reckless.
Ultimately, Feinberg’s conception of paternalism isn’t sufficient because beyond violated
involuntary action, there are instances of violated voluntary action that are justified. Note the
similarities, though, between his theory and mine. He justifies paternalism when action seems
involuntary or rash, but respects the sanctity of voluntary actions arrived at through rationality.
This seems to be reflective of autonomy in that both voluntary actions and autonomy require
rationality. I think that the concept of autonomy further embodies the respect both theories are
allotting to the moral agent and it would seem as though the contrast between liberty and
autonomy may allow for more cases of justified paternalism then allowed via the distinction
between involuntary versus voluntary action.
Gerald Dworkin defines paternalism as “the interference with a person’s liberty of action
justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or
values of the person being coerced.”11 Culver and Gert find this definition too limiting and to
prove the narrow scope of this definition, they give the case of Mr. N, who for religious reasons,
refuses blood transfusions and makes this clear to doctors upon his arrival to a hospital following
11
Dworkin, Gerald. “Moral Paternalism.” Monist. Vol 56.1. 1972. p. 65
22
extreme blood loss. He loses consciousness, and the doctor, believing Mr. N will die without
one, carries out a blood transfusion. Culver and Gert argue that this is not coercive and does not
interfere with the person’s liberty of action.12
I feel as though Culver and Gert read Dworkin’s definition too literally. While Dworkin
says ‘liberty of action,’ I never interpreted him as restricting paternalism to physical immediate
action and behavior. Liberty can also include the freedom to make choices about actions, not
just the freedom to act. In the case of Mr. N, his liberty of action is extended to his liberty to
choose action done to him, and this is violated by the physician. Dworkin’s definition of
paternalism is similar to mine – however, he does not make the distinction between autonomy
and liberty. In fact, his definition seems to permit a violation of autonomy due to a justification
based on ‘values of the person being coerced.’ I argue that the only time a person’s values may
be judged as wrongly upheld are when the values are arrived at irrationally. Without this
distinction, Dworkin runs the risk of supporting an environment where paternalistic action is
justified based on a difference of values, a situation we intuitively would not endorse.
Culver and Gert make the argument that only moral rules – killing, causing pain (mental
or physical), disabling, deceiving, breaking a promise, cheating, and depriving of freedom,
opportunity, or pleasure – require justification for breaking.13 Therefore, since paternalism also
requires justification, it must be concerned with the violation of moral rules. I find this to be a
compelling aspect of the Gert/Culver definition because as they show, it accounts specifically for
many instances we consider as paternalism (not telling a patient the truth about a delinquent son
or giving a patient a placebo treatment).
12
Culver, Charles M; Gert, Bernard. “Chapter 7.” Philosophy in Medicine : Conceptual and Ethical Issues
in Medicine and Psychiatry. New York: Oxford University Press, 1982.
13
Culver and Gert, Chapter 7
23
Culver and Gert consider three conclusions concerning paternalism – it is always
justified, never justified, or sometimes justified. The first conclusion, that paternalism is always
justified, can be defended by act-utilitarianism. This theory states that the right course of action
is that which causes the most good and/or prevents the most evil. Commonly called situation
ethics, this denies the importance of moral rules since the only required justification for action is
the caused good or averted evil. However, since situation ethics does not require moral rules, it
cannot be explain why paternalism is always justified because it is incongruous with Culver’s
stipulation that paternalism violate moral rules.
The second conclusion, that paternalism is never justified, is explained by Tom
Beauchamp who claims that we should never act paternalistically even in cases where it seems
obvious that paternalistic intervention is allowed.14 Consider this case of intuitively justified
paternalism: a friend accidentally ingested a toxin that produced suicidal tendencies. Here, we
would feel justified in preventing him from killing himself; in fact, we would judge a bystander
for not alerting him to the imminent danger. Beauchamp would agree with us, but would instead
say that in this case, this is not actually paternalism because the interfered action is not voluntary.
Culver and Gert do not find the voluntary or nonvoluntary nature of the action to be the
distinguishing feature for justification.
They defend the third conclusion, that paternalism is sometimes justified. For them, “in
order to justify paternalistic behavior, it is necessary (not sufficient) that the evil prevented for S
by the moral rule violation be so much greater than the evil, if any, caused to S by it, that it
would be irrational for S not to choose having the rule violated with regard to himself.”15 A
14
15
Culver and Gert, Chapter 8
Culver and Gert, p. 148
24
comparison of evils caused and prevented is not sufficient to justify paternalism, nor is an
assessment of the patient’s rationality adequate. They find validity in theoretical universality of
a proposed paternalistic intervention. Shying away from utilitarian constant support of
paternalism and heading down a Kantian highway, they find that if you considered a paternalistic
intervention on a universal scale, the action is justified if all rational persons will publicly
advocate the act.
If we can argue for the universality of a certain action, then it would seem odd to try to
conclude that the action may not be done, for if everyone agrees to it, then in a holistic sense, no
moral rule is violated. By this, I mean that while paternalism violates a moral rule in the
immediate sense, in the bigger picture, no rational being objects to it, so it is not immoral. If we
were all masochists, then prevention of pain would not be a moral rule, because no one would be
disquieted by its violation.
If Dworkin is concerned with a violation of liberty, then Culver and Gert are concerned with
moral rules. These are violated, not liberty. However, adherence to moral rules is what enables
the presence of liberty; therefore violating a moral rule is in turn violating liberty. The other
problem the authors find with Dworkin’s definition was the use of the word coercion. They
argue that when a patient is unconscious, paternalistic action with regards to the patient is not
coercion since the patient is not actively resisting the action. It seems strange not to see action
taken towards unconscious person to be coercive if it is an action to which the person would
otherwise object. Coercion can also be considered as domination or use of authority. In these
cases, the doctor uses his authority to order medical procedures as a way of inciting paternalistic
behavior. Additionally, if someone is ‘manhandling’ an unconscious person, they have
25
dominated them even if there was not resistance – they are making choices for the person and are
affecting what happens to the body.
While Culver and Gert’s theory is very promising because it clearly distinguishes some of the
nuances of paternalism, I think its specificity misses the overall point. For these authors,
paternalism is a violation of moral rules with respect to an individual for that individual’s benefit
without the individual’s consent. The focus on violation of moral rules can easily be summed up
as a violation of liberty. Deceit, infliction of pain, and deprivation of opportunity are all moral
rules outlined by the authors. Arguably, the violation of these moral rules are also violations of
liberty, if not directly then secondarily. Deception, pain, and limited opportunity all interfere
with the ability to choose a course of action or a person’s freedom. While I see moral rules as
synonymous with liberty, the larger objection I have to the paternalism defined by moral rules is
that no distinction is made with regards to autonomy. While these moral rules relate closely to
liberty, they also relate to autonomy. In some sense, if we think of a Kantian explanation for
morality, these moral rules stemmed from autonomous moral agents who saw the universality of
these duties. Additionally, violation of some of these moral rules may directly conflict with ends
set by an autonomous individual such as the infliction of pain. Ultimately, Culver and Gert offer
no way of insuring the sanctity of autonomy and therefore their theory fails to accommodate for
the distinction I make between liberty and autonomy.
VII. Case Studies
I have argued that autonomy is a rational setting of ends and that paternalism as an
interference with autonomy is not justified whereas paternalism as an interference with liberty is
26
sometimes justified. Let’s return now to our initial cases of Robert and Rose and explain the
intuitive decisions using my posed theoretical framework.
In the case of Robert, we would agree that paternalism is justified. Public health
concerns about the unknowing transmittance of HIV aside, we think the physician is justified in
testing Robert even though he has not consented to the test. This is a case of paternalism
because the results of the test will ultimately benefit Robert by deciding his future course of
medical treatment. To determine whether or not the act is a violation of autonomy or liberty, we
must consider what values are at play and how coercion affects the values. Robert is young and
while he is a drug-user and homeless, he hasn’t expressed any opinions with regard to the value
of his life. I would assume that it is safe to presume that unless a patient explicitly states
otherwise, the patient wants to continue to live as healthy a life as possible. The test for HIV is
minimally invasive, but the cost of lifetime treatment is high at $367,000 in Illinois.16 Unaware
of any sort of insurance Robert may have, the hospital’s procedure on treating patients who
cannot afford treatment, or any other external factor, I would argue that the cost of treatment
isn’t a viable reason to refuse information about his state of health. Living, medical expenses
aside, is expensive at the standards we expect in this country, but that doesn’t mean we value life
any less. The cost of treatment is an irrelevant aspect of Robert’s decision to not be tested.
Instead, this seems to stem from a fear of knowledge and a preference for oblivion. Robert
arrives at this preference irrationally. It indicates a lack of responsibility to himself to know his
own health and a disregard for his other values such as life. Since the decision is made
irrationally, it is not a reflection of his autonomy, and therefore paternalistic action is violating
his freedom of choice. I would also argue that this action is justified because it restores his
16
According to the Centers for Disease Control and Prevention
27
autonomy. By knowing fully the conditions affecting his body and future, he can then choose a
course of action that reflects what he values as opposed to making such choices based on limited
information.
In the case of Rose, the paternalistic action would be withholding her prognosis with the
intent to prevent her mental duress. This action is not justified because Rose has made it clear
that she wants to know information related to her medical condition. The explanation behind
this commonsense conclusion is that such information is relevant to Rose, the autonomous agent,
not just Rose, the patient exercising her liberty. Rose doesn’t want to know her medical
information for entertainment purposes; she plans on taking this information and making choices
about her treatment, her affairs, and her family. Additionally, paternalistic action in this case
seems to almost micromanage Rose’s welfare. To a certain extent, physicians must respect the
liberty Rose has to determine what is good for her. Consider the harm caused – this is not a case
where paternalism is preventing a great harm to Rose. She is already terminally ill; to be caught
up with concerns about worrying her with a prognosis seems to indicate a lack of perspective on
the situation. Ultimately, Rose has asked for the information. To not respect this request
interferes with her autonomy and is not justified.
The decisions regarding Robert and Rose are pretty uncontroversial. The following cases are
less clear and will rely less on an intuitive feeling.
Case 1.
R.L. is an 80 year-old male living with his wife in a retirement community. He values his
independence, but has recently needed to rely more on others. Difficulties include walking and
managing medications for diabetes, heart disease, and kidney problems. He starts to indicate a
loss of interest in what he once enjoyed, and his doctor diagnoses him with depression. R.L.
continues to deteriorate, gaining weight, feeling lethargic but unable to sleep. He talks about
killing himself with a gun. His doctor prescribes medication to treat the depression which R.L.
agrees to start taking. Two weeks later, before the antidepressants have a chance to take effect,
28
R.L. suffers from a heart attack and is hospitalized. Damage is extensive, affecting his kidneys
and requiring dialysis to keep him alive until it is certain whether or not his heart and kidneys
will recover. Care now requires moving him three times per week to the dialysis unit where he is
connected to a machine for up to four hours. Following his second treatment, R.L. demands
dialysis be stopped and to be allowed to die.
The paternalistic action in this instance would be for the physician to ignore R.L.’s
demands and continue dialysis, prolonging his life. Is paternalism justified in this instance?
First, we must consider what we know about R.L.’s values. He values independence which he is
obviously losing as his medical condition worsens. His suicidal thoughts and desire to end
dialysis seem to suggest that he values his independence more than the prolongation of his life.
However, we must keep in mind that these thoughts began with a diagnosis of depression. Does
depression affect the required rationality of autonomy? Since depression is an abnormal mental
state that alters perception of reality, this suggests that depressed people are not autonomous.
Given the vast number of people diagnosed with depression and the implication that an even
smaller portion of the population is therefore autonomous, this is not a conclusion I want to
endorse.
For the sake of argument, however, let’s continue to consider R.L. as irrational. One key
indicator of this is that he is no longer interested in what previously gave him joy. If he used to
love puzzles, then apathy towards puzzles precipitated by his difficulty to walk is irrational.
Walking does not affect the puzzle. This loss of interest would not be irrational if the activities
were dependent on his independence. Loss of independence would negatively impact his
activities making them less enjoyable. On the other hand, if he values his independence much
more than he values puzzles (which seems like a rational prioritization), his loss of interest in
puzzles may be relative to his loss of independence. The loss of a higher value means more than
29
the continued pursuit of a lower value. Perhaps depression indicates a loss of rationality; perhaps
it indicates a higher exercise of rationality. This paper will not be able to settle that question.
R.L.’s desire to die stems from a depressive state which is presumably treatable with
antidepressants. Given that he has not had a chance to respond to medication or dialysis, it
seems that his latest request to be taken off of dialysis is hasty and depends on his present
feeling, not on a consideration of his future state. While I find this a tough case, I would
advocate keeping R.L. on dialysis until the status of his kidneys and heart are determined. The
justification for this paternalism is that it ultimately promotes R.L.’s autonomy. If his kidneys
and heart are permanently damaged, then his request to die is rational because of the value he
places on independence. If his heart and kidneys recover, then he is able to continue
antidepressant treatment. If this treatment works and he is no longer suicidal, then we see that
depression interferes with rationality. If the treatment works and he still wants to die due to
limited mobility and the burden of medications, then depression did not interfere with rationality
and he should be allowed to end his own life. In the end, the best choice is to wait for more
information before making irreversible decisions. Paternalism is justified.
Case 2.
Patient K.B. is a 25 year-old pregnant female living in a major city in the USA. The fetal red
blood cells are being destroyed by K.B.’s Rh-sensitized immune system. The fetus will likely
die unless she receives a blood transfusion to replace the fetal erythrocytes. The intent of the
treatment is to keep the fetus alive and healthy until the fetus can be delivered. K.B. refuses
treatment – she is a Jehovah’s Witness and blood transfusions are forbidden.
The difficulty behind this case is that the choices of K.B. and the actions of the physician
are not limited to K.B. only. Paternalism in this case would involve giving a blood transfusion to
K.B. without her consent. First of all, this touches on some discussion points that typically come
out during debates regarding abortion. I support the argument that pregnant women ultimately
30
have control over their own bodies and that a distinction cannot be made between woman and
fetus until the fetus is viable outside of the womb. For K.B., we cannot argue that the treatment
is for the fetus and not for her and since the fetus holds no religious beliefs, action is justified.
While the intent of the transfusion is to affect the fetus, it still enters the mother and it still
violates her religious beliefs.
K.B.’s values stem from her religious views. Are these autonomously determined
values? In one respect, no. Religions are by nature indoctrinating – followers subscribe to a set
of beliefs. To determine if K.B.’s values are rational would require a whole other paper on the
rationality of faith. In general, I think that physicians would want to abide by the assumption
that religious values are synonymous with autonomous values. In this case, to give K.B. a blood
transfusion would be a violation of her autonomy, and it is not justified.
Case 3
C.M., a male 32 year-old, comes into the doctor’s office with headaches and blurry vision. The
physician reviews the possible diagnosis with him, one of which is cancer. C.M. says that he
does not want to know if he is terminally ill. After performing a brain scan, the physician finds
that C.M. does in fact have a tumor in his occipital lobe that is generally inoperable. However, a
new clinical trial with experimental techniques of targeting this type of cancer is accepting
patients and the physician thinks that C.M. would have good odds of surviving if he participated
in the trial.
The paternalistic choice would be to tell the patient that he has a lethal form of cancer.
The intent would be to encourage C.M. to enroll in the study and possibly beat the prognosis.
The patient values not knowing when he is going to die. A rational avoidance of this knowledge
could relate to C.M.’s concern that he would change his perceptions and live his life differently,
either becoming reckless or depressed. C.M. did not express such a concern to his physician, and
so another common understanding of his desire to not know his prognosis is fear of death.
Similarly with Robert, I would argue that knowing important aspects of one’s health is part of
31
responsibility to self. C.M. is able to act more autonomously with the knowledge of his
diagnosis – whether he wants to enter the trial, whether he wants to avoid the pain of treatment,
what activities are most important to him to complete – and so the paternalistic physician is
justified in acting.
VIII. Conclusion
After examining concepts of autonomy that are commonly used in discussion of medical
ethics, I’ve found that these more familiar definitions don’t sufficiently describe the essence of
the concerns at hand. Autonomy is holds more gravitas than simple self-governance; it is held to
high esteem and seen as inviolable. Pulling characteristics from Kantian thought, I define
autonomy as the rational setting of personal ends, a quality of a moral agent. Autonomy and
liberty/freedom are also very distinct ideas; liberty is the right to choose actions or to act freely.
Rationality is not a requirement of a free individual and free individual is not necessarily a moral
agent. Understanding this distinction, I find that a paternalistic violation of autonomy is never
justified whereas a paternalistic violation of liberty may be justified, depending on the scenario.
When paternalism is justified, does this mean we are obligated to act or simply allowed to
act if we choose to? This, I believe, is dependent on the degree of interference with an
individual’s liberty and the degree of damage to her welfare if no intervention occurs. For
instance, it may be cheaper for my friend to shop at one grocery store than another, but the
dollars saved don’t seem to be worth the violation of liberty. It takes a certain amount of
commonsense and consideration to decide if justified paternalism demands action.
32
The general concern in the medical field to protect patient autonomy is addressed by
Emanuel and Emanuel through a discussion of four models of the physician-patient
relationship.17
1. Paternalistic Model: the physician acts to ensure patients receive treatment that is in their
best interest. This can vary from selectively presenting information to sway a patient’s
decision to imposing the treatment on the patient without seeking consent.
2. Informative Model: the physician relays all information about the condition, possible
treatments, and corresponding outcomes without discussing the patient’s values.
Ultimately, the patient makes the choice for treatment herself.
3. Interpretive Model: the physician relays all medical information but also works to help
the patient articulate her values. Ultimately, the patient determines the values and the
treatment to follow.
4. Deliberative Model: the physician relays all medical information but also tries to help the
patient choose the best values related to health. Ultimately, the physician goes no further
than moral persuasion and the patient still chooses which values to prioritize.
The paternalistic model has obvious objections – it’s prevalence in the past was what ignited
the discussion for more patient autonomy. The informative model is seen as impersonal and
robotic. Many view a technically proficient physician who lacks bedside manner as defective.
Patients still want their relationship with their physician to have a caring characteristic to it. For
someone to be as intimately involved with your physical body as a physician, you would hope
that she cares that your body is treated well and cares that your interests as a patient and an
17
Emanuel, Ezekiel J; Emanuel, Linda L. “Four Models of the Physician-Patient Relationship.” JAM. Vol 267, No 16.
April 22, 1992. pp. 2221-2226.
33
autonomous individual are respected. Emanuel and Emanuel suggest that the informative model
is best used in situations of a one-time patient-physician relationship, such as in a walk-in clinic.
The interpretive model incorporates the caring element of the relationship, but is still flawed
because with limited time and technical specialization, it would be difficult for physicians to
remain completely impartial – they may accidentally impose their own values on the patient
instead of working to illuminate the patient’s values.
The deliberative model is the one which Emanuel and Emanuel endorse above all else. This
model promotes the patient’s autonomy above all else. For Emanuel and Emanuel, autonomy
“requires that individuals critically assess their own values and preferences; determine whether
they are desirable; affirm, upon reflection, these values as ones that should justify their actions;
and then be free to initiate action to realize the values.”18 The deliberative model, by involving
the physician in the argument for which values are to be upheld, makes this an active process and
ensures that physicians understand how rational their patients’ values are and safeguards against
accidental paternalistic violation of autonomy.
References:
Anderson, Elizabeth. “If God Is Dead, Is Everything Permitted?” Philosophers Without Gods: Meditations
on Atheism and the Secular Life. New York: Oxford University Press, 2007. pp. 215-230.
Culver, Charles M. Philosophy in Medicine : Conceptual and Ethical Issues in Medicine and Psychiatry.
New York: Oxford University Press, 1982.
Dworkin, Gerald. “Moral Paternalism.” Monist. Vol 56.1. 1972. pp. 64-84.
Emanuel, Ezekiel J; Emanuel, Linda L. “Four Models of the Physician-Patient Relationship.” JAM. Vol 267,
No 16. April 22, 1992. pp. 2221-2226.
Feinberg, Joel. “Legal Paternalism.” Canadian Journal of Philosophy. Vol. 1, Issue 1. 1971. pp.105-124.
Hill, Thomas. “Kantian Autonomy and Contemporary Ideas of Autonomy.” Oliver Sensen, ed., Kant’s
Conception of Autonomy. Cambridge University Press: 2013. pp. 15-31.
“HIV/AIDS: HIV Cost-effectiveness.” Centers for Disease Control and Prevention. April 16, 2013. Accessed
March 13, 2013. http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/
Mill, John Stuart. On Liberty. 1859. Kitchener: Batoche Books. 2001.
18
Emanuel and Emanuel, p. 2225
34