Paternalism I
Michael A. Gillette, Ph.D.

The discussion concerning truthfulness which has been developing over the past few months in this newsletter has posed the complex question 'when is lying morally acceptable, and when ought one to refrain from telling a lie'? The assumption behind this question is that telling lies is generally to be avoided, but that there are times when lies are permissible. The puzzle, then, is in determining what constitutes a morally acceptable lie.

While the examples that I have given previously clearly indicate that lies are permissible at times, I have also outlined some serious reasons for refraining from untruthful behavior. As noted, the physician-patient relationship may depend upon a level of trust that is secured by truthfulness. Also, individual autonomy supports the notion that people must be allowed to make their own decisions, and people need information that is accurate in order to do this well. Finally, if we start to tell lies it is often difficult to stop. Our good intentions in telling initial lies may be hard to realize as we become more and more tangled in our deceptive activities.

While this cautionary note is well taken, we must not overemphasize its value. We still lie to children when we think that it is in their own interests, and we still lie to adults when we feel that we know what it is that they want to hear. In both situations, we make judgments concerning the welfare of others. This apparent usurpation of decision making authority is at the crux of the truthfulness issue, and can be recast as a discussion of paternalism. The question is not 'should I ever lie', but rather 'when should I lie'? While we have discussed this issue previously, a more in-depth treatment may now be in order.

Paternalism can briefly be defined as the interference with a person's choices or freedom of action for that person's own welfare. A hard paternalist believes that paternalism is always justified, or that it is at least justified when the benefit to be attained is significant. The soft paternalist, on the other hand, is more concerned about respecting the subject's autonomy, and adds some stipulations to the justification of paternalistic actions. An example of one such stipulation can be found in "Paternalism: Some Second Thoughts" by Gerald Dworkin. In that article Dworkin defends a soft paternalistic position which he formulates as the claim that "(1) paternalism is sometimes justified, and (2) it is a necessary condition for such justification that the person for whom we are acting paternalistically is in some way not competent".

This formulation of the soft paternalist position is meant to safe-guard autonomy by requiring that the only situations in which paternalism is justified are those in which the subject of the intervention is already failing to act in an autonomous way. Therefore, instead of demolishing autonomy in order to bring about some good for the subject of the interference, there is no autonomy present which can be destroyed. By making this move, Dworkin can preserve autonomy at the same time that he acts paternalistically.

To apply Dworkin's position to the lying case, Dworkin would ask whether the person to whom we are lying is incompetent to make the sorts of decisions involved in our lie. For instance, if a client in an MR or MH facility will only take medication that has been prescribed by a 'physician' that he has seen on a television soap opera, then lying would be permissible so long as the client lacks the capacity to make autonomous decisions regarding medication. If the client cannot make these decisions for himself, then we must make the decisions for him. If we need to lie in order to enact those decisions, then this form of paternalism would be acceptable, and telling the client that Dr. Killdare wrote the prescription would be acceptable.

I would argue that while Dworkin is on the right track in attempting to develop an autonomy respecting paternalism, he has not gone far enough. Based on a recognition that value judgments can be very subjective, and on a desire to respect individual values, it is necessary to take into account the values of the person with whom we are interfering. The best outcome for a client who is incapable of making her own decisions is one that gives a voice to the client's own personal values. The paternalist must, therefore, take the client's values into account, and act as the client would if the client were competent.

This approach to paternalism answers many of our questions regarding lying. We lie in telling our children fairy tales because we believe that our children are not in a position to make their own decisions as to whether or not they want to enjoy this aspect of innocent youth, and because we believe that if our children could consider such facts, they would appreciate having been lied to in this way. This amounts to a type of hypothetical thank-you theory of paternalism. If the client would thank you if he were in a competent state of mind, then the paternalism is justified.

This rather complicated answer to the question concerning the appropriate occasions on which to lie may be too theoretical in its present form to be employed. How, for instance, can we possibly know what a client would want if competent? In next month's newsletter, we should return to the practicalities of a hospital setting to test the usefulness of this theoretical approach.

Source: Dworkin, Gerald, "Paternalism: Some Second Thoughts" in Paternalism Sartorius ed. (University of MI. Press, Minneapolis, MI, 1983) p.107