Perspectives in Biology and Medicine

WHO SHOULD DECIDE? PATERNALISM IN HEALTH CARE, by JAMES F. CHILDRESS* Reviewed by MARK SIEGLERt ProfessorJames Childress has written a splendid book, surely the best one thus far, on the compelling subject of paternalism in medicine. Childress, coauthor of an excellent basic philosophical text on biomedical ethics (Principles of Biomedical Ethics. New York: Oxford University Press, 1979), has been working actively in the field of medical ethics for more than a decade. He has drawn on his considerable clinical and philosophical experience to write this monograph. Throughout the book there is a welcome balance between philosophical analysis and real clinical problems. This book should be of considerable interest to both general readers and to an audience of physicians and clinical investigators whose interactions with patients might raise many of the issues discussed in this volume. Paternalism versus Autonomy For the past 20 years, the field of bioethics has been concerned with one issue more than any other: the proper relationship between paternalism and autonomy in medical practice and in clinical investigation. This tension between autonomy and paternalism has reverberated in discussions about informed consent (with respect to both treatment and participation in clinical investigation), in discussions regarding the dying patient, and in discussions about ethically acceptable models of the doctor-patient relationship. It has been the dominating motif in the work of two recent national bioethics commissions. One might refer to the modern medical era—the one that began triumphantly after World War Il and that is shuffling to its end even as I write this review—as The Age ofAutonomy. This era was created by widespread political and social movements to *New York: Oxford University Press, 1982. Pp. 250. $24.95. !Department of Medicine, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, Illinois 60637.© 1985 by The University of Chicago. All rights reserved. 003 1-5982/85/2803-0440$0 1 .00 452 I Mark Siegler ¦ Paternalism in Health Care gain entitlements and rights, to achieve equity and equality in the distribution of health services, and to dissolve the hierarchical barriers (often believed by critics of medicine to be artificial and power-oriented barriers ) between the patient (Gk: "sufferer") and the physician, the technically competent healer. The tension between patient and professional has been referred to as the "revolt of the client," a phenomenon that is increasing also in other professions and other countries. As the title of Professor Childress's book suggests, the central question on which a generation of American bioethicists have cut their teeth has been, Procedurally, where should decision-making power reside, with the physician or with the patient? A quite different question, and one that has been of much greater concern to clinicians than to ethicists, would be: What is the right and good decision for this particular patient in these circumstances? In the ethics literature, however, ideas of right and good decisions have been subordinated to procedural standards—the allocation of power—by which such decisions are reached. In this context, a "good and right" decision is one that pays sufficient heed to the wishes and presumed values of the patient—that is, one which "respects the person"—even if the patient's health problems may be so severe as to severely limit his or her capacity to make crucial, and, at times, life-anddeath decisions. "Good and right" decisions, in this view, are less concerned with outcome or with the patient's "best medical interests" than they are with respecting the patient's rights to control what is done to his or her body—". . . by respecting freedom as a side-constraint .-..," as antipaternalists such as Childress might put the point. By contrast, traditional paternalism in medicine has assigned considerable moral authority and discretion to physicians because good health was assumed to be a value shared by the patient and the physician and because physicians' competence, skills, and ability placed them in a position to help patients regain good health. This model emphasized patient care rather than patient wishes, patient needs rather than their "rights," and physician discretion rather than patient autonomy or selfdetermination . The central issue in a pluralistic society such as ours is: Under what circumstances can one justify...