Friday, February 29, 2008

The Return of Paternalism?

Paternalism is the notion of doctors unilaterally acting on the patient's behalf. It follows in that "Father Knows Best"-type of tradition (hence, the word). In recent years though, medical ethics has veered away from the traditional paternal role of the physician towards one of neutral advisor. This new ethic placed patient's autonomy as the paramount ideal. Patients were supposed to make decisions for their own care after being presented with the options in an unbiased manner by their physicians. The physician-as-agent was supposed to merely standby and execute the patient's decision. They could offer advice if asked, but had to be careful not to advocate too forcefully, lest they violate the norm of autonomy.

Of course, most patients who are not well-versed in the issues involved still rely on their doctor's assistance in making that ultimate decision. New research in psychology and behavioral economic shows that perhaps patients do in some cases need this "nudge" in the right direction. However, as the article notes, if one cannot trust the public to act in their own interests after even a "nudge," why not do more?
Many of the suggestions in “Nudge” seem like good ideas, and even, as with “Save More Tomorrow,” practical ones. The whole project, though, as Thaler and Sunstein acknowledge, raises some pretty awkward questions. If the “nudgee” can’t be depended on to recognize his own best interests, why stop at a nudge? Why not offer a “push,” or perhaps even a “shove”? And if people can’t be trusted to make the right choices for themselves how can they possibly be trusted to make the right decisions for the rest of us?
But, therein lies the problem: if doctors push, we risk the pendulum swinging too far back towards paternalism. It seems that there is a real dilemma brewing between the necessity of paternalism and the ideal of autonomy. Modern medicine so far does not seem to have a palatable answer.

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