I introduce a new distinction between two types of paternalism, which I call ‘internal’ and ‘external’ paternalism. The distinction pertains to the question of whether the paternalized subject’s current evaluative judgments are mistaken relative to a standard of correctness that is internal to her evaluative point of view—which includes her ‘true’ or ‘ideal’ self—as opposed to one that is wholly external. I argue that this distinction has important implications for (a) the distinction between weak and strong paternalism; (b) the distinction (...) between soft and hard paternalism; and (c) medical practice, where internal paternalism can, and probably often does, occur. (shrink)

ABSTRACTThis essay introduces paternalism—a concept widely discussed in political philosophy and applied ethics—into media ethics, given that the concept is frequently mentioned but rarely explicated. The purpose of the essay is to defend paternalism as a normatively positive concept. The essay defines paternalism, outlines normative objections to paternalism grounded in autonomy and rationality, and applies the concept of paternalism to journalism. Theoretical connections to virtue ethics and implications for the practice of journalism are also discussed.

Although Chinese law imposes informed consent for medical treatments, the Chinese understanding of this requirement is very different from the European one, mostly due to the influence of Confucianism. Chinese doctors and relatives are primarily interested in protecting the patient, even from the truth; thus, patients are commonly uninformed of their medical conditions, often at the family’s request. The family plays an important role in health care decisions, even substituting their decisions for the patient’s. Accordingly, instead of personal informed consent, (...) what actually exists is ‘family informed consent’. From a Western perspective, these features of Chinese law and Chinese culture might seem strange, contradicting our understanding of doctor-patient relationship and even the very essence of self-determination and fundamental rights. However, we cannot forget the huge influence of cultural factors in these domains, and that ‘Western’ informed consent is grounded on the individualistic nature of Western culture. This article will underline the differences between the Western and the Chinese perspectives, clarifying how each of them must be understood in its own cultural environment. But, while still respecting Chinese particularities, this paper advocates that China adopt patient individual informed consent because this is the only solution compatible with human dignity and human rights. (shrink)

In the past few years, medical practices surrounding the decision to resuscitate marginally viable newborns have received a fair amount of attention. Baroness Warnock, of the UK Nuffield Council on Bioethics, has recently suggested that Britain follow the recommended practice in Holland of setting a gestational age limit below which marginally viable newborns should not be routinely resuscitated, despite reported statistical probabilities of raw survival approaching twenty percent. In the US, a highly publicized case from Texas came to a controversial (...) legal conclusion, permitting physicians to disregard parental preference for palliative care and unilaterally initiate resuscitation when faced with the birth of an extremely premature baby. (shrink)

The recent and dramatic emergence of digital and other electronic technology in social work?such as online counseling, video counseling, avatar therapy, and e-mail therapy?has tested and challenged the profession's longstanding and widely accepted perspectives on the nature of both clinical relationships and core ethics concepts. These developments have transformed key elements of social work practice and require critical examination of the meaning and application of relevant ethical concepts in diverse cultures. This article explores pertinent ethical implications related to social workers' (...) commitment to clients; privacy/confidentiality; client self-determination and professional paternalism; informed consent; and professional?client boundaries and dual relationships. The author discusses the need for social workers to re-examine time-honored ethics concepts and explore their implications for the profession's ethical standards pertaining to the practitioner?client relationship. (shrink)

This essay articulates a crucial and neglected element of a general theory of the ethics of bureaucratic organizations, both private andpublic. The key to the approach developed here is the thesis that the distinctive ethical principles applicable to bureaucratic organizations are responses to the distinctive agency-risks that arise from the nature of bureaucratic organizations as complex webs of principal/agent relationships. It is argued that the most important and distinctive ethical principles for bureaucratic organizations express commitments on the part of bureaucrats (...) that function to reduce the agency risks that are inherent in such organizations. This approach to the ethics of bureaucratic organizations is shown to be more illuminating than those that concentrate exclusively or primarily on determining the conditions for corporate responsibility or on the idea that the ethical obligations distinctive of bureaucracies are role-derived. (shrink)

A distinction is made between two models of ethics committees. According to the Mirror Model, ethics committees ought to reflect the values of society. The Critical Model says committees are to critically examine these standards rather than merely reflect them. It is argued that the Critical Model should be accepted because a society's ethical standards can be mistaken and a society that has Critical rather than merely Mirror ethics committees is more likely to have such mistakes revealed. Some implications of (...) the Critical Model are discussed. (shrink)

In this essay I argue that the same considerations that justify the strong commitment to anti-paternalism that has been affirmed in bioethics over the past half century, also calls for anti-paternalistic public health policies. First, I frame the puzzle—why are citizens morally entitled to make unhealthy and medically inadvisable decisions as patients but not as consumers? I then briefly sketch the reasons why bioethicists typically reject paternalism. Next, I argue that those same reasons tell against paternalism in public health ethics (...) as well. Patients do not waive their rights to make medically inadvisable decisions when they leave their physician’s care. James Wilson disagrees. After I sketch Wilson’s arguments for paternalism in public health policy, I then argue, contra Wilson, that public health paternalism is wrong for the same reason that medical paternalism is wrong, and that the prevalence of paternalism in public policy does not mean that paternalism is morally permissible. I discuss the state’s authority to enforce paternalistic policies and I sketch an anti-paternalist vision for health policymakers. To close, I consider several objections. (shrink)

Providing patients with information is fundamental to respecting autonomy. However, there may be circumstances when information may be withheld to prevent serious harm to the patient, a concept referred to as therapeutic privilege. This paper provides an analysis of the ethical, legal and professional considerations which impact on a decision to withhold information that, in normal circumstances, would be given to the patient. It considers the status of the therapeutic privilege in English case law and concludes that, while reference is (...) made to circumstances when information (primarily in relation to risk disclosure) may be withheld, further clarification is required on the status of therapeutic privilege. I suggest there has been shift in English law relating to the standard of information disclosure towards one set by the test of the reasonable, prudent patient. It is this shift that necessitates the existence of a therapeutic privilege which enables doctors to withhold information that would usually be given to the patient in order to prevent serious harm. I then explore the professional guidance in relation to information disclosure and how this relates to the legal position. There are strong ethical arguments in favour of disclosure of information to patients. In light of these, further clarification is required to identify and define the grounds on which this exception exists, the information that could lawfully be withheld and how this exception extends to rest of the health care team, particularly nurses. As such, explicit ethical and legal scrutiny of therapeutic privilege is needed in order to consider how this concept might be articulated, constrained and regulated. (shrink)

The Willowbrook Hepatitis Study is one of the best-known examples of unethical medical research, but the research has always had defenders. One of the more intriguing defenses continually used was that critics did not know the researchers on the study and, therefore, could not assess their ethics. This essay traces the appeal to the researchers’ characters across published research and archival sources from the 1960s through today. These appeals reflect the observation as old as Aristotle that one of the most (...) potent modes of persuasion is ethos or character. The specific types of character in these appeals develop out of the paternalistic nature of clinical and research practice in the mid-twentieth century. If the individual physician is the locus of medical judgment, then the physician’s character becomes a key concern for bioethics. These appeals still appear and have implications for bioethics in the present day. (shrink)

The author examines the motives for the behaviour and actions of Dr. Skreta, the main character of Kundera’s novel The Farewell Waltz. The starting point of the novel was the social and political situation in totalitarian Czechoslovakia at the turn of the 1960s and 1970s. He compares it to the situation in the developed western world and comes to a realization that there were many similarities in medicine; however, there were significant differences with regard to external factors. The health care (...) system in western democratic societies were placed in contrast with Czechoslovakia, where a doctor’s activities and the system of health care were subordinated to the political, ideological, and social intentions of totalitarian power. In this context, the author has come to the conclusion that Dr. Skreta’s motives for acting arose from his moral responsibility for the country’s future. Dr. Skreta waged a latent personal “moral war” against the totalitarian regime. This was also reflected in his opposition to the preferred morality of socialist health care professionals. Part of this was his eugenics project. According to the author, in the context of ethics of social consequences, Dr. Skreta was a responsible moral agent seeking a better future not only for the country and its people, but his personal selfish interests. (shrink)

Un nouveau type de paternalisme s’est développé ces dix dernières années sous l’impulsion de travaux innovateurs de certains économistes comportementaux. Ce nouveau type de paternalisme, que j’appelle ici paternalisme comportemental, s’est popularisé grâce à la théorie du « coup de pouce » de Richard Thaler et Cass Sunstein et remet en question l’idée selon laquelle le paternalisme serait inacceptable dans nos sociétés. L’objet de cet article est d’évaluer sa légitimité morale sans, néanmoins, se limiter à son supposé libertarianisme. Les résultats (...) de mon investigation peuvent se résumer ainsi : bien que le paternalisme comportemental soit généralement reconnu pour son caractère libéral, il ne satisfait pas en fait les conditions de ce que Joel Feinberg nomme le « paternalisme mou ». Néanmoins, il possède des qualités morales sous-estimées par ses partisans. Il résiste d’abord très bien à la critique égalitariste d’Elizabeth Anderson. A la différence des formes traditionnelles de paternalisme, le paternalisme comportemental n’est pas dégradant et n’est pas ostracisant. Le paternalisme comportemental, enfin, peut se targuer d’être véritablement altruiste, à la condition, cependant, d’abandonner les hypothèses principales de Sunstein et Thaler. Classification JEL : A12, D64, I18, I31, K32. (shrink)

This article defines the nature of paternalistic interventions in psychotherapy and discusses reasons why the client's right to consent to treatment is important. We describe a reasoning process developed by Culver and Gert (1982) that can be used to determine when paternalistic actions are and are not ethically justifiable in mental health practice. We demonstrate how this procedure may be applied to psychotherapy by using a number of case illustrations.

In 2008 the Human Fertilisation and Embryology Act amendments made deliberately choosing to bring disability into the world, using assisted reproduction, a criminal offence. This paper considers whether the legal prohibition above, should influence other policy areas concerning the welfare of future children such as new possibilities presented by foetal surgery and in utero gene therapy. If we have legal duties to avoid disability in one context should this influence our avoidance of disability in this other context? This paper investigates (...) whether the State might have a stake in wider promotion of practices to reduce the degree of disability in foetuses that will come to exist. Not selecting for disability does not affect the welfare of any future individual, whereas treating in utero abnormalities can optimize the eventual child’s welfare; antenatal interventions stand to improve clinical outcomes and welfare should that specific child be born. I explore why the State may want to intervene in the antenatal setting and to what extent, if at all; the State should implement these technologies. I argue that if the State is justified in intervening to outlaw the choosing to create disabled lives using assisted reproductive techniques, it is also justified in putting pressure on prospective parents to accept therapies in utero to help their child be born less disabled. However, I qualify this with the argument that the State is not justified in using force or the criminal law in this situation during pregnancy. (shrink)

Decisions to provide life-sustaining medical care for marginally viable newborns present a unique set of morally complex challenges for providers and parents in the United States. This article examines recent legal trends that restrict discretionary decision-making, and critiques commonly employed ethical justifications offered to support permitting such discretion.

Is there ever any reason for a doctor to lie to a patient? In this paper, we critically review the literature on lying to patients and challenge the common notion that while lying is unacceptable, a related entity--'benevolent deception' is defensible. Further, we outline a rare circumstance when treating psychotic patients where lying to the patient is justified. This circumstance is illustrated by a clinical vignette.

The paper presents a comparative analysis of the evolution of the legislative process concerning ART in the specific cultural, societal and political contexts of two countries- Slovakia and Germany. Our analysis is based on 1. mapping the variety of discourses on ART in order to gain an understanding of the perspectives of the main actors and their arguments; and on 2. exploring the reasons for the differences in the current regulation of ART among European Union member states. In both Slovakia (...) and Germany we found there was a deficit of democratic legitimacy, because the arguments and experiences of those primarily affected by the restrictive measures on the use of ART in medical care-infertile women and men-are not taken into consideration with any seriousness. On the contrary, government and legislators pay too much attention to the ethical opinions of the Catholic Church. Government intervention in Germany is highly problematic because there is no sufficient justification of the reasons behind restrictions on parental autonomy and the procreative freedom of women and men. Moreover, the restrictions are not consistent across an array of similar cases and are not applied equally to all. Instead of an interventionist approach which protects the embryo against its own potential mother, it would be more sensible to adopt the “women-centered” approach already suggested by several authors. It holds that both the mother and embryo have to be at the centre of bioethical and legal considerations, instead of there being an exclusive reliance on ethical principles and expert opinions with regard to the embryo alone. (shrink)

“Informed consent” is a legal instrument that allows individuals to define their own interests and to protect their bodily privacy. In current medical practice, patients who have consented to surgery are considered to have implied consent to anaesthesia, even though anaesthesia is associated with its own particular set of risks and consequences that are quite separate from those associated with surgery. In addition, anaesthetists often perform interventions that are the only medical treatment received by a patient. Anaesthetists, therefore, should always (...) obtain separate consent for anaesthesia, and should regard the process of consent as a stimulus for active, fluid reciprocal discussion with patients about treatment options. (shrink)

The ethical theories employed in health care today assume, in the main, a modern Western philosophical framework. Yet the diversity of cultural and religious assumptions regarding human nature, health and illness, life and death, and the status of the individual suggest that a cross-cultural study of health care ethics is needed. A Cross-Cultural Dialogue on Health Care Ethics provides this study. It shows that ethical questions can be resolved by examining the ethical principles present in each culture, critically assessing each (...) value, and identifying common values found within all traditions, It encourages the development of global awareness and sensitivity to and respect for the diversity of peoples and their values and will advance understanding as well as help to foster a greater balance and a fuller truth in consideration of the human condition and what makes for health and wholeness. (shrink)