The Moral Issue Of Paternalism And Truth-Telling

The Moral Issue of Patients’ Rights

BSN 1C- Group No. 5

Submitted by:

1. Ediza, Louise
2. Ediza, Lanz Eli
3. Fernandez, Philip
4. Fletcher, Denis
5. Ingreso, Estelle Brianne
6. Jabonillo, Katrina
7. Labus, Ester Denise

April 20, 2021

 The Moral Issue Of Paternalism And Truth-Telling

In ancient China, a Confucianist thinker named Meng Tze or Mencius (ca.

371-289 B.C.) stated that there are “four beginnings” that differentiate man from the
beasts; hence they should be developed, because it is only through their
development that man becomes truly human (Fung Yu Lan 1948: 68-70): (1) The
feeling of helpfulness and commiseration, which is the beginning of human-
heartedness; (2) the feeling of shame and dislike, which is the beginning of
righteousness; (3) the feeling of modesty and yielding, which is the beginning of
propriety; and (4) the sense of right and wrong, which is the beginning of wisdom.”
According to Mencius, these “four beginnings,” if fully developed, become the four
constant virtues: human-heartedness, righteousness, propriety, and wisdom.

Our departures in this chapter is Mencius’s concept of human-heartedness or

the feeling of helpfulness and commiseration. “All men,” explains Mencius, “have
mind which cannot bear to see the suffering of others... If now men suddenly see a
child about to fall into a well, they will without exception experience a feeling of
alarm and distress” (Fung Yu Lan; 69-70). What Mencius is telling us here refers to
what psychologists claim lies deep within the human psyche- it is the desire to help
others, the feeling of benevolence or good will, a sense of compassion with the
desire to help, to be of service, to give assistance whenever it is needed.

The biblical story of the Good Samaritan best exemplifies and support this
dimension of human nature. For Mencius, this sense of helpfulness or human-
heartedness consists in loving others. We desire to help because we love others.
Christians refer to this as a sense of charity, kindness, or benevolence, which reflects
that we earlier considered to be the principle of benevolence and/or non-maleficence.

On the other hand, the principle of autonomy-- otherwise known as the right
of self-determination-- affirms that an individual is autonomous. Hence he has the
right to act and decide by and for himself. He can choose who he wishes to be, and
take responsibility for such a choice.

It seems that respect for an individual’s autonomy and right of self-

determination presupposes noninterference and nonintervention with his choice or
plan of action and moral decision. Generally speaking, however, paternalism involvs
some sort of interference with the individual’s freedom of action. This is the moral
issue of paternalism.

9.1 Definition And Types Of Paternalism

From the Latin word pater ‘father’ or paternus ‘fatherly’. Paternalism means
the act of being fatherly to someone, as if the latter were one’s own offspring.
Strictly speaking, it consists in acting like a father to a person for the latter’s own
and good interest. This is in keeping with the principle of nonmaleficence and with
Mencius’s sense of human-heartedness. It is argued that a paternalistic act is
believed and intended to protect or advance the interest of its recipient, although
such an act may go against the latter’s own immediate desires or may limit his
freedom of choice. (Pahl: 213-214). Is a paternalistic act, therefore, morally
legitimate? Will it not circumvent and undermine the recipient’s right of self-
determination or autonomy?

Let us first identify several types that define the general idea of paternalism,
and indicate their different aspects, before we present the moral justifications.

4. With regard to the patient’s sense of values, paternalism can either be soft or
hard. In soft paternalistic act, the patient’s values are used to justify the intervention
with his possible action or decision. An unconscious or comatose patient, for
example, is usually detached from life-support machines because he/she earlier
signified such preference if ever he/she would be put in sucha a situation. (Hence, a
Filipino would say “Kapag ako’y nag-aagaw buhay na, huwag na ninyo akong ikabit
sa artificial respirator.” )

In hard paternalism, on the other hand, the patient’s values are not the ones
used to justify the paternalistic act. For example, someone who supposedly knows
what is good for a patient directs the latter with regard to what is to be done or
directs someone else to do this for the patient, “Mas mabuti para sa iyo kung
magpaopera ka na ngayon,” or a husband would tell his wife attendant physician:
“Doc, mabuti pa kaya’y gawin nang Caesarean and panganganak ng misis ko.”

5. With regard to the recipient of the benefit, Paternalism may be either direct or
indirect (Childress:14). In the case of the former, the individual who should receive
the supposed benefit is the one whose values are overridden or disregarded for his
own good. The motorcyclist, for example, who is forced by law to wear the helmet is
the one who will benefit in case of an accident. In the case indirect paternalism, a
particular individual will be benefited, if one person is restrained from doing
something. A good example is child abuse, in which parents are restrained by law in
some way to protect the child.

9.2 In The Medical Context

We can speak of personal and state paternalism in its application in the

medical context. (Pahl:214-217): (1) Personal paternalism is one in which an
individual decides on the basis of one’s best knowledge of what is good for another
person. On the basis of a physician’s own principles and values, for instance, the
physician makes the decision in the best interest of one’s patient. In such a situation
the physician acts in a way that deprives the patient of genuine and effective choice.

To give an example, a member of the Plymouth Brethren sect disdains the

shedding of blood, and so refrains from being operated on for acute appendicitis;
but upon suffering a ruptured appendix, this person lapses into unconsciousness.
The surgical resident then operates and saves this person’s life (Pahl: 213). Here the
attendant doctor performs a paternalistic act for the benefit of the nonconsenting
patient.

(2) State paternalism, on the other hand, refers to the exerted by the
legislature, an agency, or other governmental bodies over particular kinds of
practices and procedures in medicine. Such control is exercised through the
compliance with certain laws, licensing requirements, operational guidelines and
regulations in medical practice. All behavioral therapists for instance, must be either
licensed psychologists or psychiatrists; all practicing doctors must pass the medical
board examination.

9.3 Justification For Personal Paternalism

(1) The recipient of the paternalistic act is sick and consults the physician
seeking medical expertise and assistance; (2) the recipient of the paternalistic act
has some incapacity which prevents him/her from making a decision. Or, the person
is under stress, suffers a nervous breakdown, is a minor, or his/her judgment is
impaired in one way or the other; (3) to the best of one’s knowledge and training,
there is the probability of harm unless a paternal decision is made; here one needs
to determine if all harms are equal (e.g., physical, mental, and social); (4) the
probable benefit of paternal intervention outweighs the probable risk of harm from
noninterference; (5) the physician has an obligation to act in the best interest of the
patient; and (6) the patient, upon consulting the physician, voluntarily transfers part
of his/her autonomy to the latter based on faith in the physician (Pahl:216-217;
Shannon 1987:14).

9.4 Justification For State Paternalism

(1) To improve the good quality of medical education (e.g., issuing a set of
policies or practices); (2) to upgrade a high standard of medical care (rigorous
standards and strictly enforced laws, for example, have done much to improve
medical practice); (3) to control drug addiction, other drug abuses, or the spread of
AIDS and other sex-related diseases (Pahl: 214-216).

9.6 Truth-Telling

When patient agrees to place himself under the care of a doctor, by virtue of
the fact that the former consults the latter for medical care, the power of the
physician over the patient cannot be absolute; that is, the patient does not become
a helpless slave or creature to the physician. Thus, the physician-patient relationship
involves the moral issue of truth-telling and confidentiality. Is it justifiable for a
doctor to deceive his/her patient? How much autonomy mus be given up by the
patient? What are the limits of paternalism that can be legitimately exercised by the
doctor?
Let us first deal with truth-telling: Does a patient have the right to know the
truth about himself/herself (i.e., the nature and extent of the ailment)? Does a
physician have the obligation to tell the truth to a patient?

Two approaches to the truth-telling issue may be cited: the person-centered

and problem-centered. The former lends importance to the patient as a person while
the latter stresses the nature of the problem, or the degree and severity of the
patient’s illness (Fletcher 1954). In other words, the person-oriented approach
considers the patient as a person with a problem, but not as a problem
himself/herself. The patient is a person with feelings of hope and despair, with
purpose and defeat. As such, one has the right to know the nature of one’s disease
and the physician is morally obligated to respect that right. The physician owes the
patient the truth, just as the latter owes the doctor skill and technical powers.
Moreover, caring for a person is a moral relationship in which the physician’s attitude
should be an utmost concern for the patient.

The problem-oriented approach, on the other hand, considers the patient’s

problem, illness, or condition. The physician may not tell the truth when it is the best
interest of the patient; after all the physician is fallible and makes mistakes. Thus, if
only for the best interest of the patient’s failing or worsening condition, the physician
may withhold the truth from the patient. This approach is usually appealed to by
those who endorse the legitimacy of the use of placebos (Latin placebo, ‘I shall
please’) in medical therapy. Patients who are given seriously ill will oftentimes show
improvement when they are given placebos for treatment. This can happen even
when medication is irrelevant to their condition.

John Fletcher compares the twofold approach to truth-telling with what Martin
Buber defines as two types of relationship: the I-it and the I-thou (Fletcher 1954).
The “I-it” relationship describes a person’s relationship with things, objects, or “its”;
hence, an “I-it” or man-object, subject-object relationship. This kind of relationship
is determined by our attitude to what is other than ourselves. My relationship with
my books, cars, eyeglasses, shoes, clothes, and other possessions typify the “I-it” or
subject-object relationship. Insofar as these things are my possessions or personal
properties. I can manipulate and use them for own purpose and ends.

“I-thou” relationship, on the other hand, delineates our relationship with other
persons like ourselves, other subjects, I’s, thou’s or you’s; hence, “I-thou” or “I-I”,
subject-subject, person-person relationships. Insofar as the other person is a fellow
human being, a thou or someone with integrity and a moral quality of his/her own, I
cannot manipulate or use him/her without degrading or dehumanizing him/her at
the same time. For persons like myself, are not things or objects that are usable or
manipulable by other persons

In the medical context, the physician-patient relationship exemplifies an “I-

thou” or person-person relationship, inasmuch as both persons are “I’s”. This type of
relationship is a moral experience because persons can respond, i.e. they are
responsible; unlike things, they can say “yes” or “no”; they can make decisions. In
short, they have rights, especially the right to self-determination, the right to be
themselves, to choose to be a “you” rather than an “it”. In Fletcher’s view, if a
patient simply becomes an object of medical treatment, who submits himself to a
physician, without any knowledge of his condition and its prognosis, that patient has
ceased to be a “thou” and has become an “it”. He is being used and manipulated as
if he were a thing or object; he is no longer accredited as a person, and hence is
deprived of personal responsibility and moral status.
9.7 Justification For Truth-Telling

(1) It is argued that our human and moral quality as persons is taken away
from us if we are denied whatever knowledge is available about our condition as
patient, as the case may be; (2) As patients, we have entrusted to the physician any
knowledge he has about ourselves, so the facts (i.e., his findings) are ours and not
his -- hence, to deny them to us is to steal from us; (3) The highest conception of
the physician-patient relationship is a personalistic one which is based on mutual
confidence and respect for each other’s rights; and (4) To deny a patient pertinent
knowledge about himself, especially in a life-and-death situation, is to deprive him
the ample time to prepare for his own death or to carry out responsibilities that are
based solely on his decisions or actions (Fletcher 1954; Pahl: 217-220).

9.8 Confidentiality

Confidentiality (from the Latin confidene ‘to trust’) refers to medical or

professional secrecy in which certain information (i.e., secret finding) is committed
to a physician in an official capacity for the sake of medical assistance (Pahl:220-221;
Walters 1987: 169-175). This is in conjunction with one provision of the Hippocratic
Oath: “Whatever I see or hear, professionally or privately, which ought not to be
divulged, I will keep secret and tell no one.” The practical function of confidentiality
in a physician-patient relationship underscores the confidence and trust that the
patient has for the physician. With this feeling of confidence, the patient is not
reluctant but cooperative in giving personal information to the physician.

The moral issue of confidentiality arises if and when there is a conflict

between individual interest (i.e., patient’s interest) and the interest of society (i.e.,
the common good). The physician is placed in the middle of a conflict between the
interest of the individual and the interest of society. Doctors, for example, are
required by law to reveal certain information about their parents. This legal
obligation enjoins them to report the names of patients who are carriers of
communicable diseases (e.g., AIDS, syphilis, T.B.) to health departments. If the
physician acts to protect the patient’s trust, then he is acting contrary to law; if he
acts in accordance with the law, he violates the confidence of his patient.

It is argued, however, that confidentiality is not absolute. Under certain

conditions, it is better to violate it than to preserve it. Confidentiality can be violated
if it is necessary to produce conditions which will bring about happiness and well-
being. Let us consider these instances: if someone’s life is in great danger, then
confidentiality loses its binding power. Or, if the testimony of a physician is needed
to help establish the innocence of someone who is being tried for a crime he did not
commit, then charity demands that the innocent party be protected and the secret
be divulged. Physicians, it must be noted, are also members of society, and the
latter must attempt to protect the general interest.

Four conditions may be cited to justify the violations of confidentiality: (1)

when keeping the secret would be detrimental to the common good; (2) when the
subject of the secret intents to inflict grave injury upon an innocent third party; (3)
when it is necessary for the subject of the secret to avert gave injury; and (4) when
it is necessary for the one keeping the secret to avoid grave injury (Pahl; Walters
170-173; Bittle: 360-366).

The Moral Issue of Patients’ Rights

Rights are necessary because every individual lives in a community of persons

in relation. “No man is an island,” so the saying goes (Merton 1967: 9-17). Man is a
being-with-others in the world. For this reason, human life is more meaningful and
worth living only in the presence and help of others, in communion with others, and
for benefit of others. This holds true for all kinds of human relationships, including
physician-patient relationships. A patient, like the physician, is an individual human
being endowed with reason and freedom. As such, he/she enjoys natural and
inalienable rights, such as the right to life and the right to privacy, among others.

10.1 Meaning of Patients’ Rights

What is meant by patient’s? In medical context, a patient’s right means the

moral and inviolable power vested in him as a person to do, hold, or demand
something as his own. (Bittle: 276, 303; Feinberg: 38-44; Shannon and Digiacomo:
145-153). By nature, every person enjoys a moral and inviolable power (i.e., right)
to do, hold, enjoy, and exact those things proper to one’s whole being. Every right in
one individual involves a corresponding duty in others to respect this right and not to
violate it. As the patient enjoys some rights, for example, the doctor must respect
these rights. Duty therefore, is the correlative of right. A right is something mine or
yours, something that belongs to a person by nature; it is sometimes, but not always
reinforced by law. Hence, everyone ought to respect another person’s right. The
moral oughtness (Obligation) to do or omit something in favor of another according
to the demands of strict justice known as duty. (Bittle: 277; Shannon 1987:14-16).

From the foregoing, if the patient has the right to do, hold, or demand
something, it is the duty of the physician not to interfere with this right; rather he
has the obligation to perform or omit an action corresponding to the patient’s right.
This obligation arises from strict justice--i.e., giving the patient his own due by
nature. Only in this way can equality between one person and another-- which is the
essence of justice-- be realized and established.

10.2 Types Of Patient’S Rights

The right to self-determination (also known as the principle of autonomy)

mentioned in chapter One as one of the major themes in bioethics literature, is the
central element in the moral issue of patients’ rights. The patient, as an individual
person, has the moral right to determine what is good for himself. This right is an
important consideration in the discussion of patients’ rights in the medical context
(Beauchamp and Childress 1979:62-94; Varga: 102-103; Beauchamp and Walter:
134-137; Pahl: 120-264): (1) right to informed consent; (2) right to informed
decision; (3) right to informed choice; and (4) right to refusal of treatment
 Right to informed consent. The patient has the right to receive all necessary
information concerning diagnosis and treatment in order to be able to give consent
based on his/her value system. “Informed consent” refers to the knowledge or
information about and the consent to a particular form of medical treatment, before
that treatment is administered. The information should include the risks and
advantages of any medical treatment that concerns the patient.
Right to informed decision. Information and understanding are necessary for
genuine deliberation. The patient cannot make a moral decision unless these two
important elements are present. “Informed decision” refers to the necessary
information of a decision on a medical treatment before the latter is carried out. The
patient must be informed about the whole process and must understand what this
information pertains to so that an appropriate moral decision can be arrived at.

Right to informed choice. “Informed choice” refers to the necessary

information a patient should know about a medical treatment or experiment so that
a moral choice can be made. The patient has the right to be informed about all
possible alternative courses of action to be taken, together with the possible
consequences. In reality, however, “informed consent, decision and choice” go
together in moral decision-making. As soon as the patient has been informed about
what the process involves and has understood it, he or she will either consent to it
or will not. Whichever is the case, a decision is made, and whatever decision arrived
at becomes the patient’s moral choice.

In short, as the patient consents to undergo treatment, he or she decides on

it; as the patient makes a decision, he or she makes a choice between two or more
alternatives. Thus, the emphasis on “informed consent” involves the information and
agreement or disagreement, consent or nonconsent; “informed decision”, the
information and the decision made; and “informed choice,” the information and the
choice taken from among several alternatives; “Refusal of Treatment”, the patient
has the right to decide on what is the best option, choice or alternative for their
body.

10.3 Four Major Elements Of Informed Consent

1. Competence.This refers to a patient's capacity for decision-making.(Shannon:

1013; Beauchamps and Childress: 66-82). One is considered competent when
(a) one has made a decision (i.e., one can choose between alternatives); (b)
one has the capacity to justify one's choice (i.e., give reasons for one's
choice)--competence here requires some process of deliberation, justification
and an articulation of why one has made this particular choice; (c) one does
not only justify one's choice but does so in a reasonable manner.

2. Disclosure. This refers to the content of what a patient is told or informed

about during the concept negotiation. The patient must be informed and must
understand the information concerning medical treatment to be undertaken
so that a moral decision can be made . The disclosure of information must be
conducted in such a way that the patient understands the whole process and
 is aware of the possible outcomes of his or her moral choice. Should there be
a language bar year between the physician and the patient an interpreter
might be consulted to communicate the pertinent information.

3. Comprehension. This refers to whether the information given has been

understood. The disclosure of information is not enough; equally important is
the comprehension of that information. if the patient does not understand
what he or she has been told, then information has not been relayed at all.
Health care professionals have a professional language and so they are
expected to translate their jargon so that it will be intelligible to their patients.
They must be sensitive to their patient’s needs.

4. Voluntariness. This means that the consent must be voluntary. The patient
must of his own free will agreed to become the research subject, as the case
may be. He/she must make a choice without being unduly pressured by
anyone else. Being free in making a decision needs that the patient owns the
decision, that decision is the patient’s alone, that the patient has chosen the
option based on the information disclosed to him/her.

Right to refusal of treatment. In conjunction with the “Statement on a Patient’s Bill

of Rights” presented by the American Hospital Association, “the patient has the right
to refuse treatment to the extent permitted by law and to be informed of the
medical consequences of his action” (Beauchamp and Walters: 140; Beauchamp and
Childress: 82-84). In many instances, a patient may refuse medical treatment
because their religious convictions prohibit them from doing so (e.g., a patient who
is a member of a particular sect may refuse to undergo blood transfusion). Many
regard this right to refuse treatment as fundamental in a free society, especially
among those who advocate the freedom or right to die if and when the prevailing
circumstances warrant it. Moreover, the invasion of a person’s body (e.g. the patient)
without valid consent is an assault, and physicians may be subjected to legal
sanctions.

10.4 Limitations Of A Patient’S Rights

1. Patient's rights do not include the right to be allowed to die (Hegland 1981: 266-
272). Under the concept of personal paternalism, the physician may make the moral
decision for and on behalf of the patient who can no longer decide by end for
himself, as in the case of a comatose patient. It is the sworn duty of the attending
physician to do whatever is medically possible to save the patient's life.

2. A patient in a moribund condition does not possess the necessary mental or

emotional stability to make an informed choice. a dying patient or one who lapses
into unconsciousness, becomes mentally incompetent to make a decision. In such a
situation the attending physician may perform a paternalistic act for the well being
of the patient.

3. Patients' rights are not absolute. Paternalistic concern limits the competent adult
patients freedom of choice (e.g., refusal of treatment) for his or or her own good in
order to prevent harm from be falling that patient/ This precept is enshrined in the
Hippocratic oath: “I will apply dietetic measures for the benefit of the sick according
to my ability and judgment; I will keep them from harm and injustice" (Beauchamp
and Walters: 138)

10.5 In the Medical Context

In actual medical practice in the Philippines, there are two methods of

obtaining informed consent: First, is a written consent, which is a consent form to be
filled up in and signed by patent as he/she checks in or admission in a hospital. This
practice, by all indications, appears to be only perfunctory, because the clerk or
admission personnel does not bother to explain the content of the consent form to
the patient. Usually, the latter will just sign it. The second is a verbal consent.
Whenever the patient verbally signifies his/ her willingness to undergo medical
treatment, informed consent is met. Verbal consent i usually made after a physician
has briefed the patient about the medical process to be undertaken (Alfidi: 251-253)

In emergency cases, however, the following types of patients need not

require informed consent: (1) comatose or obtunded patients; (2) blind or illiterate
patients; (3) underaged patients or those unable to understand the circumstances;
and (4) language-barrier patients. In principle, the parents, immediate relatives,
guardians, or next of kin should be informed when the patient is comatose, blind or
illiterate, underage or unable to understand the language of the physician. In actual
experience, however, the expediency of the situation may be such that the physician,
exerting a Solomon-like judgment, may not have time to consult the patient’s next of
kin. In emergency situations, for instance, time is of the essence. An instant decision
is a matter of life and death. A physician’s delayed action may be fatal to a particular
patient.

10.6 The Rights Of Patients

Following are twelve rights of patients as they are documented in the

American Hospital Association’s (AHA) “Statement on a Patient’s Bill of Rights”
(Beauchamp and Walter :140-141; Pahl: 244-245).

1. The patient has the right to considerate and respectful care.

2. The patient has the right to obtain from his physician complete current
information concerning his diagnosis, treatment, and prognosis in terms that
the patient can be reasonably expected to understand.

3. The patient has the right to receive from his physician information necessary
to give informed consent prior to the start of any procedure and/or treatment.

4. The patient has the right to refuse treatment to the extent permitted by law
and to be informed of the medical consequences of his action.

5. The patient has the right to every consideration of his privacy concerning his
 own medical care program. (The issue here is one of privacy and simple
courtesy.)

6. The patient has the right to expect that all communications and records
pertaining to his care should be treated as confidential.

7. The patient has the right to expect that, within its capacity, the hospital must
provide a reasonable response to his/her request for services.

8. The patient has the right to obtain information regarding any relationship of
his hospital to other health care and educational institutions insofar as his
care is concerned.

9. The patient has the right to be advised if the hospital proposes to engage in
or perform human experimentation affecting his/ her care or treatment. The
patient has the right to refuse to participate in such research projects.

10. The patient has the right to expect reasonable continuity of care. (The
patient has the right to know in advance what appointment schedules and
physicians are available and where.)

11. The patient has the right to examine and receive an explanation of the
hospital bill, regardless of source of payment.

12. The patient has the right to know what hospital rules and regulations apply
to his/her conduct as a patient.

10.7 Application Of Ethical Theories

Natural law ethics regards the right to informed consent as morally legitimate.
Should a patient decide to give his/ her consent, it must be given freely and not the
consequence of intimidation, deception or coercion. Under the principle of
stewardship and the inviolability of life, natural law ethics seems to be against the
patient’s right to refusal of treatment if the latter means an act of commission
and/or an acts of omission which results in self-killing (suicide)or euthanasia.