Paternalism II
Michael A. Gillette, Ph.D.

Our discussion of paternalism has brought to our attention three distinct types of situations in which it might be necessary for one person to make decisions for someone else. The first case involves an individual who is completely competent and who has clear reasons for making choices, but who makes choices with which we disagree. Nevertheless, we find it appropriate to honor these choices. The best example of this sort of situation is when we, non-Christian Scientists, honor the decision of a Christian Scientist to refuse medical care.

The second situation of interest involves a completely incompetent patient who has no capacity to make the relevant choices, and for whom some action must be taken. The best example of this situation would be a patient who is brought into the emergency room in a drug induced delirious state and is in need of immediate surgery. We make the choice to go ahead with the surgery even over the vehement objections of the patient.

In the first case we reason that the patient has specific values regarding the treatment at hand, and that those values must be honored. In the second case we reason that the stated preferences of the patient do not accurately reflect the patient's values, and that by ignoring the objections we will most likely benefit the patient in a way that he really would want to be benefited, if only he could decide competently now.

A third possible scenario is more troubling. How should we deal with the wishes of a patient that are clearly based on long-standing values, and yet seem entirely unreasonable?

The example given previously to illustrate problems of this type involves Ms. D. She is a 40 year old schizophrenic woman who has been treated for years but continues to experience very consistent auditory hallucinations. Ms. D's remarkably consistent delusional experiences support her belief that she ought not to accept psychotropic medication. Ms. D is certain that the survival of the human race depends on her drug refusal.

The first and most successful move in a situation like this is to go back to the first two cases to look for guidance. If we consider why we were willing to honor the patient's choice in case one but not in case two, it becomes clear that we feel confident that in case one the patient is espousing values that are authentic to her character. The Christian Science adherent seems to understand the ramifications of her actions and possesses a coherent set of values that supports her refusal of care. We may not feel that her evaluation of the outcome is accurate, unless we share her view of religion, but we can see that she is a person whose character can truly be defined along the lines of Christian Science.

This is precisely what we do not believe about the patient in case two. He is suffering from a state of mind that we believe is causing him to act in ways that are inauthentic to his character. We believe that when the effects of the drugs subside, he will be happy that we went ahead with the necessary surgery over his objections. The "thank you" theory of paternalistic intervention is at work here. Do what the patient really wants, not just what he says he wants. And what someone really wants is what is most consistent with his most basic and consistently held values.

Now, if we shift back to case three, we have some means of approach. If we feel that the woman in case three is making decisions secondary to her mental illness, and not decisions that she would really want to make, then case three is analogous to case two and we ought to intervene. If, on the other hand, we feel that treatment refusal is consistent with the most basic values that the patient holds, then we ought not to intervene.

Many people who suffer from mental illness would like to be able to live their lives in ways that they cannot express when under the influence of the disease process. It makes sense in most cases to consider the influence of mental illness to be analogous to the influence of drugs. And in these situations, paternalistic intervention is morally justified.

Where, however, does mental illness leave off and a quirky character pick up? Where does an aberration in the thought process start, and an acceptable eccentricity begin? There are thousands of people in this country who make very strange choices, and yet we do not feel compelled to intervene. In fact, there are some very strange thought processes that even gain favor and fame even though they involve serious harm (e.g. the dare-devil who has an unreasonably low level of risk-aversion).

The problem that we now face is that if the only appeal we can make in order to determine whether intervention is permissible is the appeal to underlying character, how do we deal with someone whose underlying character is defined by their unusual thought processes? How do we deal with an individual who has grown up with a mental illness or with mental retardation and is now the type of person who cannot be understood apart from that illness or disability? What do we do with a person whose underlying character, whose authentic values, support the apparently unacceptable choice? In order to honor such a person's autonomy we must not intervene, and yet failure to intervene is very dangerous from our point of view.

Obviously, if harm to others is an issue, we have reason to get involved. But for present purposes I would like to focus on purely paternalistic interventions. Why should we intervene to help a person make his life go better by our standards when that person does not want our intervention (authentically), and no other person will be harmed if we remain inactive? One answer to this question is that we ought not to intervene. It is morally best, one might argue, to let such people "rot with their rights on". But should we let people harm themselves just because they really want to?

The number of people who fall into the category now under discussion is likely to be a tiny proportion of the people who present for care. I suggest, however, that the answer we give when considering this small subset of patients will have far-reaching ethical implications. I will attempt, therefore, to outline the results of this line of thinking in future discussions.