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Thursday, December 12, 2013

What is paternalism?

My friend and ACP senior staff advocate on public policy Bob Doherty has a response to my recent blog post about political philosophy. Is it “paternalistic” to set minimum standards for health insurance?



Is it really paternalistic for the government to set minimum standards for health insurance? Paternalism means that someone—in this case—the government, is second-guessing the choices that I might make for myself and my family, because it believes that it knows better than me. But is that what is really going on with Obamacare’s minimum standards for health insurance?

Yes Bob, that is paternalism. This complete philosophical discussion might help – Paternalism

Physicians are currently taught that we should focus on patient centered decision making rather than paternalism. This distinction actually is not as clear as one might first imagine. When we tell patients to accept vaccines, we almost universally take a paternalistic attitude. Few physicians criticize that form of paternalism. Yet most internists believe that we should allow patient informed decision making when deciding whether or not to have prostate cancer screening.

Given some particular analysis of paternalism there will be various normative views about when paternalism is justified. The following terminology is useful.

Hard vs. soft paternalism

Soft paternalism is the view that the only conditions under which state paternalism is justified is when it is necessary to determine whether the person being interfered with is acting voluntarily and knowledgeably. To use Mill’s famous example of the person about to walk across a damaged bridge, if we could not communicate the danger (he speaks only Japanese) a soft paternalist would justify forcibly preventing him from crossing the bridge in order to determine whether he knows about its condition. If he knows, and wants to, say, commit suicide he must be allowed to proceed. A hard paternalist says that, at least sometimes, it may be permissible to prevent him from crossing the bridge even if he knows of its condition. We are entitled to prevent voluntary suicide.

Broad vs. narrow paternalism

A narrow paternalist is only concerned with the question of state coercion, i.e. the use of legal coercion. A broad paternalist is concerned with any paternalistic action: state, institutional (hospital policy), or individual.

Weak vs. strong paternalism

A weak paternalist believes that it is legitimate to interfere with the means that agents choose to achieve their ends, if those means are likely to defeat those ends. So if a person really prefers safety to convenience then it is legitimate to force them to wear seatbelts. A strong paternalist believes that people may be mistaken or confused about their ends and it is legitimate to interfere to prevent them from achieving those ends. If a person really prefers the wind rustling through their hair to increased safety it is legitimate to make them wear helmets while motorcycling because their ends are irrational or mistaken. Another way of putting this: we may interfere with mistakes about the facts but not mistakes about values. So if a person tries to jump out of a window believing he will float gently to the ground we may restrain him. If he jumps because he believes that it is important to be spontaneous we may not.

Pure vs. impure paternalism

Suppose we prevent persons from manufacturing cigarettes because we believe they are harmful to consumers. The group we are trying to protect is the group of consumers not manufacturers (who may not be smokers at all). Our reason for interfering with the manufacturer is that he is causing harm to others. Nevertheless the basic justification is paternalist because the consumer consents (assuming the relevant information is available to him) to the harm. It is not like the case where we prevent manufacturers from polluting the air. In pure paternalism the class being protected is identical with the class being interfered with, e.g. preventing swimmers from swimming when lifeguards are not present. In the case of impure paternalism the class of persons interfered with is larger than the class being protected.

Moral vs. welfare paternalism

The usual justification for paternalism refers to the interests of the person being interfered with. These interests are defined in terms of the things that make a person’s life go better; in particular their physical and psychological condition. It is things like death or misery or painful emotional states which are in question. Sometimes, however, advocates of state intervention seek to protect the moral welfare of the person. So, for example, it may be argued that prostitutes are better off being prevented from plying their trade even if they make a decent living and their health is protected against disease. They are better off because it is morally corrupting to sell one’s sexual services. The interference is justified, therefore, to promote the moral well-being of the person. This then can be called moral paternalism. Still another distinction within moral paternalism is between interferences to improve a person’s moral character, and hence her well-being, and interferences to make someone a better person—even if her life does not go better for her as a result.

Finally, it is important to distinguish paternalism, whether welfare or moral, from other ideas used to justify interference with persons; even cases where the interference is not justified in terms of protecting or promoting the interests of others. In particular moral paternalism should be distinguished from legal moralism, i.e. the idea that certain ways of acting are morally wrong or degrading and may be prohibited. So, for example, the barroom “sport” of dwarf tossing (where dwarfs who are paid, and are protected with helmets, etc. participate in contests to see who can throw them furthest) might be thought to be legitimately prohibited. Not because the dwarf is injured in any way, not because the dwarf corrupts himself by agreeing to participate in such activities, but simply because the activity is morally degrading and wrong.

To be sure it is not always easy to distinguish between legal moralism and moral paternalism. If one believes, as Plato does, that acting wrongly damages the soul of the agent, then it will be possible to invoke moral paternalism rather than legal moralism. What is important is that there are two distinct justifications that are possible; one appealing to the mere immorality of the conduct interfered with, the other to the harm done to the agent’s character.

Both sides of the political spectrum resort to paternalism. Some on the right take a paternalistic view based on morals – drug laws, anti-abortion laws, sodomy laws (for example). Some on the left takes a paternalistic view on health care, gun control, taxing the rich.

The big problem in this example is the tone of the talking points when individual policies were cancelled, and the new policies were much more expensive. Accusing the victims was clearly perceived as a paternalistic attitude. And that was the point.

The health care law, like many laws, induces winners and losers. The losers will likely consider this law paternalistic.

Paternalism per se is not inherently a bad thing. As physicians we often use paternalism. These financial victims will not easily accept this law positively. Blaming the victims was a bad strategy. The recent apology was a step in the right direction.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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