Ronald Dworkin argues on the basis of a theory of well-being that critical paternalism is self-defeating. People must endorse their lives if they are to benefit. This is the endorsement constraint and this paper rejects it. For certain kinds of important mistakes that people can make in their lives, the endorsement constraint is either incredible or too narrow to rule out as much paternalism as Dworkin wants. The endorsement constraint cannot be interpreted to give sensible judgements when people change their (...) minds about the value of their lives. And the main argument for the endorsement constraint, which is based on the value of integrity, does not support Dworkin's anti-paternalism. (shrink)

Screening for unsuspected disease has both possible benefits and harms for those who participate. Historically the benefits of participation have been emphasized to maximize uptake reflecting a public health approach to policy; currently policy is moving towards an informed choice approach involving giving information about both benefits and harms of participation. However, no research has been conducted to evaluate the impact on health of an informed choice policy. Using psychological models, the first aim of this study was to describe an (...) explanatory framework for variation in screening uptake and to apply this framework to assess the impact of informed choices in screening. The second aim was to evaluate ethically that impact. Data from a general population survey of beliefs and attitudes towards participation in diabetes screening indicated that greater orientation to the present is associated with greater social deprivation and lower expectation of participation in screening. The results inform an explanatory framework of social patterning of screening in which greater orientation to the present focuses attention on the disadvantages of screening, which tend to be immediate, thereby reducing participation. This framework suggests that an informed choice policy, by increasing the salience of possible harms of screening, might reduce uptake of screening more in those who are more deprived and orientated to the present. This possibility gives rise to an apparent dilemma where an ethical decision must be made between greater choice and avoiding health inequality. Philosophical perspectives on choice and inequality are used to point to some of the complexities in assessing whether there really is such a dilemma and if so how it should be resolved. The paper concludes with a discussion of the ethics of paternalism. (shrink)