Paternalism, reasonableness, and neutrality: a response to commentators image

Journal of Medical Ethics, September 2017, Vol. 43 No. 9
Frances Kamm (former Senior Fellow)


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From the article (from the commentary on Frances Kamm's earlier article, "Advanced Care and End of Life Care: Some Cautionary Suggestions."

I thank the commentators for their consideration of my views and for their insightful suggestions.

Robert Truog thinks that doctors can first emphasise patients’ preferences but end by advocating what they think are objective goods because when patients’ views are not knowledgeable, doctors see a conflict between respect for autonomy and beneficence.

Some concerns about Truog’s views are: (1) He describes autonomy as a ‘sociological trend’ characteristic of our culture, but there may be a normative justification for emphasising individual autonomy. Often it is normatively justified for persons to decide on matters about which they know little and others much (eg, checking out of a hospital against doctors’ advice). (2) What sometimes alters matters may be what Truog calls doctors’ ‘moral agency,’ when they would have do what they conclude is objectively wrong. In his example, parents want their dying child who will soon be removed from a ventilator to also be taken off sedation so they can have meaningful time together. Doctors know that because the child will panic at his inability to breathe, the parents will not get what they want and will get something they do not want (ie, the child’s panic). I think this case is like one involving ‘soft paternalism’: there is no disagreement between parents and doctors about whether an end is valuable but only about whether stopping sedation is a means to achieving it. It is like Mill's case of someone who wants to get to the other side of a river but does not know that the bridge is broken. We may interfere with his using the bridge because it would not achieve what he wants and achieves what he does not want. By contrast, the cases I discussed involved different opinions about ends rather than means. For example, I argued that the view that peacefulness and non-invasive support constitute a good death is not the only reasonable view. When there are multiple reasonable views, a doctor should not be as concerned that his involvement would be wrong. (3) I agree that doctors should make vivid the possible costs and benefits of options. This is why I worried that some end of life decision guides do not require that patients be fully informed but only get the information they prefer.

Dominic Wilkinson focuses on the possibility, desirability and reasonableness of professional neutrality. His comments on the first two overlap with Schenker and Arnold’s, which I shall deal with later. The third concerns his view that despite reasonable disagreement about what way of dying is best, we should agree that some ways of dying are bad. He gives the example of death by torture undertaken for its own sake and claims that “deaths that occur in the setting of high technology medicine appear dangerously close to ‘death by torture’.” He says that doctors should not be neutral towards treatments at the end of life that (A) ‘lack benefit’ and (B) ‘risk substantial suffering.’ [...]

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