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With reference to the article "Hear my concerns and I will take your recommendations seriously" the following comments about doctor patient and family patient communication may be more relevant today.:
Human rights are entitlements we have because we are human and some rights are protected by law.1 In the practice of medicine paternalism is the term used to describe how doctors from time immemorial have engaged with the rights of patients in their best interests. 2 Next of kin have also exercised a similar paternalism when deciding on behalf of sick relatives. Times have moved on and people are more vulnerable due to dwindling family size, fracturing social cohesion, emigration and immigration. 3 When a person lacks capacity for medical decisions, supports are needed to assist the person. Hence Capacity Legislation and decision support structures. However when a person has a family doctor or other doctor and caring relatives should they not continue to avail of their help in medical decision making as always?4,5
“The will and preference of the patient” has now superseded “What is in the patients best interests“. This is a fundamental shift of philosophy which decries the paternalism of the past when the family, next of kin and doctor made decisions in the best interest of patients with reduced capacity. This is an ethical challenges for medicine to determine the golden mean between this rights-based approach and good paternalism.2,6,7 The human attributes of affect, understanding and support confer a deeper knowledge of what illness means for an individual person and can confer a better understanding of what genuine human rights are. Unfortunately these attributes have now come to have the pejorative name of “paternalism.”
A person is free to make unwise decisions but they shouldn’t be allowed to do so unwittingly. The situation of a vulnerable person making a decision based on expert advice with a decision making assistant is a key issue. This may be the only solution when no close relative or doctor is available. If there are close relatives or a trusted doctor these should be the decision making assistants. True autonomy and genuine informed consent imply an understanding of long term and short term repercussions of any decision and the effects of no decision. The “rights- based approach” is at risk of allowing vulnerable people make decisions without having a coherent and responsible grasp of what their decision means in real terms. People who know the person well and have good will (paternalism) can be vital in ensuring a rash decision is not made. Vulnerable people should not make a decision “just because I want to and it’s my decision“- and experience a false fleeting autonomy at the cost of a long term bad outcome. This is subordinating beneficence to a false autonomy. It is rights-based (with a superficial understanding of rights) but may lack comprehensive evaluation of consequences.
“The most important, and hopefully sustainable progress worldwide has not come from techniques but from an idea – the idea of universal and inalienable human rights."8,9 However, truthfulness about the past is also essential. Most paternalism in the past was good. 10 Some opine that it was open to abuse of power. Undoubtedly there were and are cases of abuse but the worldwide experience of paternalism and the overwhelming reality is that it was necessary effective and compassionate for those in need of protection advice and advocacy. A “rights based” approach tends to disparage this wealth of meaning and caring and supplants it with a legal framework. 11
1 United Nations Website. Human Rights. Accessed 5.11.14. 7
2Lepping P, Palmstierna T, Raveesh BN. Paternity v. autonomy – are we barking up the wrong tree? BJPsych, 2016;209(2);95-96. Doi:10.1192/bjp.bp.116181032p.bp116.181032.
3. Pimlott N. The Ministry of loneliness. Can Fam Physician. 64(3);166;2018.
4. Buchanan A. Medical paternalism or imperialism: not the only alternatives for handling Saikewicz-type cases. Am J Law Med. 5(2);97-117.1979.
5. Chin JJ. Doctor –patient relationship: from medical paternalism to enhanced autonomy. Singapore Med J. 43(3);152-5. 2002.
6. Steinert T. Shifting the pendulum – but with checks and balances. World Psychiatry 2024: 23: 388-389. 2024 DOI:10.1002/wps.21232
7. Gather J, Scholten M. Aligning the “single law proposal to the CRPD standard of “will and preferences”. World psychiatry 2024; 23; 389-391.
8. Galderisi S, Appelbaum PS, Gill N et al. Ethical challenges in contemporary psychiatry: an overview and appraisal of possible strategies and research needs. World Psychiatry 2024;23:364-86.
9. Zelle H. Advance care planning: a multifaceted contributor to human rights based care. World Psychiatry 2024:23; 391- 392.
10. Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: paternalism versus patient –centred (autonomous) care. Curr Opin Crit care. 14(6):708-13;2008. DOI: 10.1097/MCC.0b013e328315a611
11. Kapoor R. What is wrong with a rights-based approach to morality? J Nat Law Univ Delhi. 2019: Volume 6, Issue 1 https://doi.org/10.1177/2277401719870004
Competing interests:
No competing interests
13 March 2025
Eugene Breen
Associate Clinical Professor, Consultant Psychiatrist
Is Paternalism all bad and Rights Based Medicine all good?
Dear Editor,
With reference to the article "Hear my concerns and I will take your recommendations seriously" the following comments about doctor patient and family patient communication may be more relevant today.:
Human rights are entitlements we have because we are human and some rights are protected by law.1 In the practice of medicine paternalism is the term used to describe how doctors from time immemorial have engaged with the rights of patients in their best interests. 2 Next of kin have also exercised a similar paternalism when deciding on behalf of sick relatives. Times have moved on and people are more vulnerable due to dwindling family size, fracturing social cohesion, emigration and immigration. 3 When a person lacks capacity for medical decisions, supports are needed to assist the person. Hence Capacity Legislation and decision support structures. However when a person has a family doctor or other doctor and caring relatives should they not continue to avail of their help in medical decision making as always?4,5
“The will and preference of the patient” has now superseded “What is in the patients best interests“. This is a fundamental shift of philosophy which decries the paternalism of the past when the family, next of kin and doctor made decisions in the best interest of patients with reduced capacity. This is an ethical challenges for medicine to determine the golden mean between this rights-based approach and good paternalism.2,6,7 The human attributes of affect, understanding and support confer a deeper knowledge of what illness means for an individual person and can confer a better understanding of what genuine human rights are. Unfortunately these attributes have now come to have the pejorative name of “paternalism.”
A person is free to make unwise decisions but they shouldn’t be allowed to do so unwittingly. The situation of a vulnerable person making a decision based on expert advice with a decision making assistant is a key issue. This may be the only solution when no close relative or doctor is available. If there are close relatives or a trusted doctor these should be the decision making assistants. True autonomy and genuine informed consent imply an understanding of long term and short term repercussions of any decision and the effects of no decision. The “rights- based approach” is at risk of allowing vulnerable people make decisions without having a coherent and responsible grasp of what their decision means in real terms. People who know the person well and have good will (paternalism) can be vital in ensuring a rash decision is not made. Vulnerable people should not make a decision “just because I want to and it’s my decision“- and experience a false fleeting autonomy at the cost of a long term bad outcome. This is subordinating beneficence to a false autonomy. It is rights-based (with a superficial understanding of rights) but may lack comprehensive evaluation of consequences.
“The most important, and hopefully sustainable progress worldwide has not come from techniques but from an idea – the idea of universal and inalienable human rights."8,9 However, truthfulness about the past is also essential. Most paternalism in the past was good. 10 Some opine that it was open to abuse of power. Undoubtedly there were and are cases of abuse but the worldwide experience of paternalism and the overwhelming reality is that it was necessary effective and compassionate for those in need of protection advice and advocacy. A “rights based” approach tends to disparage this wealth of meaning and caring and supplants it with a legal framework. 11
1 United Nations Website. Human Rights. Accessed 5.11.14. 7
2Lepping P, Palmstierna T, Raveesh BN. Paternity v. autonomy – are we barking up the wrong tree? BJPsych, 2016;209(2);95-96. Doi:10.1192/bjp.bp.116181032p.bp116.181032.
3. Pimlott N. The Ministry of loneliness. Can Fam Physician. 64(3);166;2018.
4. Buchanan A. Medical paternalism or imperialism: not the only alternatives for handling Saikewicz-type cases. Am J Law Med. 5(2);97-117.1979.
5. Chin JJ. Doctor –patient relationship: from medical paternalism to enhanced autonomy. Singapore Med J. 43(3);152-5. 2002.
6. Steinert T. Shifting the pendulum – but with checks and balances. World Psychiatry 2024: 23: 388-389. 2024 DOI:10.1002/wps.21232
7. Gather J, Scholten M. Aligning the “single law proposal to the CRPD standard of “will and preferences”. World psychiatry 2024; 23; 389-391.
8. Galderisi S, Appelbaum PS, Gill N et al. Ethical challenges in contemporary psychiatry: an overview and appraisal of possible strategies and research needs. World Psychiatry 2024;23:364-86.
9. Zelle H. Advance care planning: a multifaceted contributor to human rights based care. World Psychiatry 2024:23; 391- 392.
10. Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: paternalism versus patient –centred (autonomous) care. Curr Opin Crit care. 14(6):708-13;2008. DOI: 10.1097/MCC.0b013e328315a611
11. Kapoor R. What is wrong with a rights-based approach to morality? J Nat Law Univ Delhi. 2019: Volume 6, Issue 1 https://doi.org/10.1177/2277401719870004
Competing interests: No competing interests