Special Feature – Medical Ethics Essay
Singapore Med J 2002 Vol 43(3) : 148-151
Deconstructing Paternalism – What Serves the Patient Best? N H S S Tan (This Essay won the Singapore Medical Association Ethics Essay Award (Non-medical Undergraduate Category) in 2001.)
ABSTRACT On the motion that “medical paternalism serves the patient best”, this essay reviews current arguments on medical paternalism vs. patient autonomy. Citing medico-ethical texts and journals and selected real-life applications like electroconvulsive therapy (ECT) and the advanced medical directive (AMD), the essay argues that medical paternalism cannot serve the patient best insofar as current debates limit themselves to “who” wields the decision-making power. Such debates side-step “what” the patient’s best interests are. The essay further argues through the case of Traditional Chinese Medicine (TCM), and acupuncture in particular, that the current dominant Western school of thought excludes other forms of “alternative” treatment through medical paternalism. Singapore Med J 2002 Vol 43(3):148-151
N H S S Tan Second-year mass communication student at Ngee Ann Polytechnic Correspondence to: Noel Hidalgo Tan Suwi Siang Email: noelbynature@ pacific.net.sg
Although probably not written by Hippocrates (c. 460 – c. 477 BC) himself, the Hippocratic Oath is one of the oldest, most binding code of conduct today. The oath expresses the aspirations of the physician, and sets the ethical precedent by spelling out the physician’s responsibilities to the patient and the medical profession. Today, the Hippocratic Oath has been adopted and adapted world-wide; all physicians take the oath in some form or another. In Singapore, the doctor who undertakes the Singapore Medical Council’s Physician’s Pledge promises to “make the health of my patient my first consideration” and “maintain due respect for human life” (pars. 4, 9). The primary concept behind the oath is the principle of beneficence, which is operationalised in the original oath as the resolve to serve “for the benefit of the sick according to (the physician’s) ability and judgement” (cited in Mappes & DeGrazia, 1996; p.59). The principle of beneficence, indeed the over-emphasis of it, also led to medical paternalism or the physician’s prerogative to act
on his or her best judgement for the patient. R S Downie observed, “The pathology of beneficence is paternalism, or the tendency to decide for individuals what they ought to decide form themselves” (cited in 1996; p.5). More often than not, medical paternalism tends to focus more on the patient’s care and outcomes rather than the patient’s needs and rights. In recent years, medical paternalism has come under fire through the concept of patient autonomy, or the patient’s right to choose and refuse treatment. While the debate between autonomy and paternalism still remains unresolved, paternalists argue that “maximum patient benefit” can be achieved only when the doctor makes the final medical decision (Weiss, 1985; p.184). The pro-autonomy stance maintains that “benevolent paternalism is considered inappropriate in a modern world where the standard for the client-professional relationship is more like a meeting between equals than like a father-child relationship” (Tuckett, Boulton, Olson & Williams, cited in Nessa & Malterud, 1998; p.394). This essay argues that medical paternalism cannot serve the patient best insofar as current debates sidestep the principle of beneficence in favour of decision-making power and medical paternalism under the current dominant Western school of thought excludes other forms of treatment. Current debate surrounding paternalism has always been centred on the issues of autonomy and paternalism and reduced further into a power struggle between the doctor and patient. This polarisation of the decision-making power has distracted the medico-philosophical debate. Today’s traditional medical values like “pain is bad” and...
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