Autonomy vs. Paternalism: A Contest Between Virtues

Providing health care is a shared practice, in which the expert and the consumer both work to be sure that what is delivered is satisfactory to each. As the expert, the practitioner knows what is needed in a pure medical sense, but does not know how the value preferences of the patient will affect what part of the care will be accepted.

Since there is a general agreement that, thorough the exercise of personal autonomy, the patient has the right to decide the nature of care, it is vital that the practitioner make sure that the decision is based on appropriate information. Informed consent is required for all invasive or risky procedures that have potential for harm. The physician must disclose pertinent details about the  nature and purpose of the procedure, its risks and benefits, and any reasonable alternatives to the recommended treatment.

There have been several standards for this disclosure of information, but today most practitioners recognized the reasonable patient standard, which requires that the information be explained in such a manner that a hypothetical reasonable person could understand and make decisions. Because all of us are unique in what we value, it may be time to develop a more subjective standard than that of a “reasonable” person.

While there is a general agreement that the autonomous adult has the right to decide these issues, there are times when the autonomy of the patient is limited by the pain, trauma, age, and mental competency. Competency is usually established in the ability to answer two questions in the affirmative: First, does the patient understand the nature of the condition and the various options available; and, second, is the decision making process rational? The second question is somewhat modified when the decision is based on a protected religious faith, rather than reason.

Paternalism in its best sense is based on the principle of beneficence and a desire to do well for the patient. In modern health care, this desire to do good is not a justification for overcoming a competent patient’s personal autonomy.


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