Blog | 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.