What is the difference between beneficence and paternalism

The presumption in bioethics, especially bioethics in the United States, that medical paternalism was an accepted ethical norm and therefore common clinical practice in the history of medicine is described and then called into question. This discussion suggests that the importance of medical paternalism for the future of bioethics has become an open question.

Skip to main content Skip to table of contents. This service is more advanced with JavaScript available. Encyclopedia of Global Bioethics Edition. Editors: Henk ten Have. Contents Search. Authors Authors and affiliations Laurence B. Reference work entry First Online: 16 July How to cite.

This is a preview of subscription content, log in to check access. Beauchamp, T. Reich Ed. New York: Macmillan. Google Scholar. Principles of biomedical ethics. New York: Oxford University Press. The concept of paternalism in biomedical ethics. The study was conducted in seven psychiatric clinics for adults four that offered general psychiatric care, two forensic psychiatric care and one addiction care and six child and adolescent psychiatric clinics.

All clinics had the surrounding region as their respective catchment area. The clinics chosen can be considered to be regular Swedish psychiatric clinics with heterogeneous patient populations managed by six county councils in central Sweden.

Staff members on the wards who worked directly with the patients were invited to participate in the study, regardless of occupational status. We only obtained background information such as professional category, education and age, from the adult psychiatric wards.

Staff members in child and adolescent psychiatry were, however, guaranteed anonymity, as there are relatively few employees in each county. Approximately half of the staff members were mental health care assistants.

Registered nurses constituted the majority of the other half, while the remainder comprised various professional categories such as psychiatrists, psychologists, social workers and teachers.

The participants were asked to keep an ethical diary for a period of one week. The diary had eight pages; the first contained instructions and the following were blank, except for the name of the day. We also asked for ideas and thoughts inspired by these considerations. We suggested that they should write down their experiences every day after finishing work.

Qualitative theory-guided content analysis was used in order to capture a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives [ 20 , 21 ]. Engstrom [ 4 ] previously conducted a more extensive review of these three perspectives. NVivo8 was used to identify all the values in this review. Based on this analysis we obtained an initial list of 28 values Table 2 , which were used as initial codes [ 20 ].

This was the theoretical base used for the empirical analysis. All statements in the diaries that contained any kind of description of encounters with patients were analysed, however, statements that had no reference to a patient were omitted. NVivo 8 was used to categorize the statements that then were placed in one of the three perspectives on the basis of the balance of power that was described. They were finally placed in a code that the statement referred to.

To obtain a manageable amount of codes we merged codes that had many statements in common and that seemed to relate to similar value issues. With the ethical diary followed instructions and a letter with information about the background and purpose of the study, and that participation was voluntary. In our data we found that the majority of the statements were examples of the perspective of paternalism, while several also referred to autonomy.

However, only a few could be attributed to reciprocity. The result is related to the three perspectives and contains eight values Table 4. Paternalism; 1 promoting and restoring the health of the patient, 2 providing good care and 3 assuming responsibility.

Reciprocity; 1 involving patients in the planning and implementation of their care and 2 building trust between staff and patients. Each value is illustrated by a quotation and the final quotation in every perspective is a reflection on working contrary to the value. The participants expressed the importance of working in the best interest of patients, which is fundamental in the perspective of paternalism.

They wanted to promote and restore the health of the patient. If necessary, coercive treatment could be administered in the best interest of the patient.

Legally approved coercion was rarely considered ethically problematic. However, informal coercion, such as psychological pressure involving persuasion or the threat of coercion more often gave rise to ethical considerations. His description of how unwell he feels when he has to take medication and of how well he copes without it is very convincing. Since the patient is in compulsory care, we can determine what is good and bad treatment. The participants aimed to provide good care.

They could take time to talk to and calm patients when required. Sometimes they lacked the time and the patient received medication instead. There were also strategies in place to prevent violence on the ward. They worried about patients who, in their opinion, did not have adequate support from the social services. Meeting about a home placement for a patient on long-term leave. However, it is the municipality that pays and the officials want a different type of accommodation.

However, a few statements revealed that some staff members were loyal to the patient rather than the organisation, despite being aware of the fact that their actions could lead to problems with colleagues.

The participants also wanted to assume responsibility for the patients and their well-being. Some went beyond their professional role by taking more responsibility for patients than was expected.

When patients were unable to assume responsibility for their actions, the staff could take over. Sometimes this could lead to situations where patients in voluntary care were treated as if they were in coercive care. Many of these paternalistic statements convey an impression of staff members acting in a way that they believe is beneficial for the patient.

Last week a patient hit a staff member on the head with a plastic bottle. In my view it is both, but above all the purpose is to emphasise that such behaviour is unacceptable. Many participants seemed to be aware of the risk of developing such an attitude, as in their diaries they were critical of colleagues who acted in this way.

Several threats to patient autonomy were reported. One was lack of resources, which sometimes resulted in limitations on patient autonomy. Being permitted to go outdoors and other activities could be limited if staff members lacked the time to assist. Another risk was that ward practices, routines and rules were often extensive, and patients and staff were expected to respect them.

Relatives could request information about the patient, which was problematic if the patient did not wish to inform them. Occasionally the staff decided to withhold information from patients, for example incoming mail or details about their care planning, in order not to create anxiety on the ward.

Ward routines included conducting diagnostic tests, and at times management demanded tests, but it could happen that patients refused to participate. This is a difficult question, which often arises. They reflected on how to perform certain tasks in a way that minimises violation of integrity, e. A young female patient under continuous observation expresses that it is a violation not to be allowed to close the toilet door.

Compromise; a 5 cm gap so that I can see her knees and she is told to turn on the tap in the washbasin, which she does and thinks it helps somewhat. There were also statements revealing thoughts or behaviours where the participant or a colleague had no or only little respect for patient rights.

Some participants perceived violations by colleagues and criticized their behaviour or language. Nevertheless, none of the participants actually noted down that they had reported violations against patients to their superiors and only a few considered doing so. Some statements pertained explicitly to protecting human rights.

The other day I had a discussion with a colleague about accompanying a patient who is a Muslim to the mosque. Freedom of religion? The participants described striving to involve patients in the planning and implementation of their care. One way to do this was to listen to the patients and ask about their wishes. Although staff members felt pressure from management and colleagues to maintain a professional distance to patients, some participants, especially in child and adolescent psychiatry, chose to have a closer relationship with patients.

However, they did not tell colleagues about their commitment to patients in order to avoid criticism. I received an e-mail from the little Iranian girl today.

I have a great relationship with her. It is difficult. The participants expressed the need to build trust between staff members and patients. They could become frustrated when they failed to create a good relationship with patients and, in the case of child and adolescent psychiatry, with parents. Some participants were committed to their work and clearly shared the joy of patients when they were happy or the treatment outcome was positive.

Weight gain, great joy, both for me and the patient. Some participants found it very difficult to control their negative feelings about certain seriously ill patients. They did not want any kind of reciprocity and instead sought to distance themselves from these patients.

He has no empathy towards his victim. I find it very hard to cope with disturbed people. The three concepts; paternalism, autonomy and reciprocity, reflect different ethical perspectives in the development of medical ethics in psychiatry.

There is a long tradition of paternalism in psychiatry, but patient rights and reciprocity have been considerably more in focus in recent decades. This commission was established in by the U.

Congress with a charge to discover and publish the basic principles of human research ethics and also to "consider" the boundaries between biomedical research and accepted medical practice. The commission found that beneficence is one of only three basic principles of research ethics. This principle soon became and remains today one of three canonical principles in American research ethics governing research funded by the federal government.

The three basic principles are 1 respect for persons, 2 beneficence, and 3 justice. In this context, the principle of beneficence is understood as an abstract norm that includes derivative rules such as "Do no harm," "Balance benefits against risks," and "Maximize possible benefits and minimize possible harms.

As one major demand of beneficence, the National Commission required that during the course of the ethical review of research protocols there be arrayals of data pertaining to benefits and risks and of alternative ways of obtaining the benefits if any sought in the research.

It also demanded that systematic and nonarbitrary presentations of risks and benefits be made to subjects, as part of the informed consent process, and that assessments of risks and safeguards be considered by ethics committees when they evaluate whether research protocols are justified.

The moral concern is that some subjects, notably children, would be overburdened and possibly disturbed or terrified. However, the commission recognized that risks must be permitted during the course of many forms of research, including pediatric research, in order for investigators to be positioned to distinguish harmful from beneficial outcomes. Today, the problem might be expressed in terms of the need for investigators to determine the safety or effectiveness of a therapy or diagnostic tool under investigation in a study.

This understanding of beneficence and its role in protecting human subjects is deeply embedded at the core of research ethics in many countries.

Beneficence has played a major role in a central conceptual issue about the nature and goals of medicine as a social practice. If the end of clinical medicine is healing, which is a goal of beneficence, then arguably medicine is fundamentally a beneficent undertaking, and beneficence grounds and determines the professional obligations and virtues of the physician.

Authors such as Edmund Pellegrino write as if beneficence is the sole foundational principle of professional medical ethics. In this theory, medical beneficence is oriented exclusively to the end of healing and not to any other form of benefit. The category of medical benefits does not, for Pellegrino, include items such as providing fertility controls unless for the prevention and maintenance of health and bodily integrity , performing purely cosmetic surgery, or actively helping a patient to effect a merciful death by the active hastening of death.

This characterization of the ends of medicine allows Pellegrino to limit severely what counts as a medical benefit for patients: Benefit in medicine is limited to healing and related activities such as caring for and preventing injury or disease. This thesis is controversial. Even if healing and the like are interpreted broadly, medicine does not seem to many in bioethics to have such precise boundaries. If these are bona fide medical benefits, how far does the range of benefits extend?

If a physician runs a company that manufactures powered wheel chairs for the elderly, does this activity supply a medical benefit? When physicians consult with an insurance company about cost-effective treatments that save their patients money, is this activity a beneficent component of the practice of medicine? Controversy over the ends of medicine requires decisions about what is to count as the practice of medicine and, derivatively, what counts as medical beneficence.

Controversy appears not only in the literature of biomedical ethics, but also in some split decisions of the U. Supreme Court—notably in Gonzales v. Oregon , a case dealing with physician-hastened death. The majority decision in this case asserts that there is no consensus among health care professionals about the precise boundaries of the legitimate practice of medicine , a legal notion similar to the medical-ethics notion of the proper ends of medicine.

The court notes that there is reasonable disagreement in the community of physicians regarding the appropriate process for determining the boundaries of medical practice and that there is also reasonable disagreement about the extent to which the government should be involved in drawing boundaries when physicians themselves disagree.

This court opinion allows that, depending on state law, a physician may legitimately assist in various ways to help bring about the death of a terminally ill patient who has explicitly and competently requested this assistance from the physician.

Physician-hastened death by request of the patient — controversially characterized as physician-assisted suicide—is again a prominent example of this problem.

Physicians and nurses have long worried that patients who forgo life-sustaining treatment with the intention of dying are killing themselves and that health professionals are assisting in their suicide.

These worries have recently receded in significance in biomedical ethics, because there is now a consensus in law and ethics in the U. This consensus began to be developed with the case of Karen Ann Quinlan in and eventually was formed around U.

Supreme Court decisions, especially the Cruzan Case of The writings of numerous philosophers and lawyers contributed to the formation of this consensus. A clear part of the consensus is that it is a moral violation not to withhold or withdraw a validly refused life-sustaining treatment. However, this problem has been replaced by another: Is it harmful or beneficial to help a competent patient who has requested help in causing a hastened death?

In addition to vexed questions about the purported distinction between killing and letting die, this issue presses the question of what counts as a benefit and what counts as a harm. Is requested death in the face of miserable suffering a benefit for some patients while a harm caused to other patients?

When is it a benefit, and when a harm? Is the answer to this question determined by the method used to bring about death--for example, withdrawal of treatment by contrast to use of lethal medication? A number of controversial issues in biomedical ethics concern how public policy could, and should, change if obligations of social beneficence were given more strength in policy formulation than they have traditionally been afforded.

The foundations of public policy regarding organ procurement provide an instructive example. Established legal and policy precedents in many countries require express consent by a decedent before death or by the family after death. A near absolute right of autonomy to decide about the disposition of organs and tissues has been the prevailing norm.

However, this approach impairs the efficient collection of needed tissues and organs, and many people die as a result of the shortage of organs. The scarcity of organs and tissues and the inefficiency of the system have prompted a spate of proposals for reform of the current system of procurement, with the goal of creating more space for social beneficence.

One policy proposal with a notably strong social-beneficence commitment is the routine retrieval of organs and tissues. In this system of procurement, a community is permitted to, and encouraged to, routinely collect organs and tissues from the deceased, unless the dead person had previously registered his or her objection to the system with the state. The routine retrieval of tissues and organs from the deceased is regarded by many as unjustified on traditional grounds of respect for autonomy.

However, advocates of the policy of routine retrieval argue that members of a community have an obligation to provide other persons with objects of lifesaving value when no cost to themselves is required. That is, the justification is based on beneficence, not respect for autonomy. The debate is likely to continue for many years about whether beneficence or respect for autonomy should prevail in public policy governing organ retrieval.

Advocates of the current system argue that individual and family rights of consent should retain dominance. Advocates of routine retrieval argue that traditional social priorities involving beneficence in conflict with autonomy have been wrongly structured. Meanwhile, most contributors to the literature on the subject agree that the present situation of low-level organ-procurement is morally unsatisfactory and in need of some significant measure of reform.

Some of the most important issues in the ethics of health and health care today are widely classified as issues of social justice. However, at the hands of many writers, social justice is notably similar to social beneficence.

For example, perhaps the most important moral problem in global ethics is how to structure both the global order and national systems that affect health so that burdens are avoided, benefits are provided, and then both are fairly distributed using a threshold condition of equitable levels of health and access to health care. Globalization has brought a realization that problems of protecting health and providing beneficial services are international in nature and that their alleviation will require a restructuring of the global system.

Rawls argues that a social arrangement forming a political state is a communal effort to advance the good of all in the society. His starting assumptions are layered with beneficent, egalitarian goals of making the unequal situation of the naturally disadvantaged members of society both better and more equal.

His recognition of a positive societal obligation to eliminate or reduce barriers that prevent fair opportunity and that correct or compensate for various disadvantages has implications for discussions of both beneficence and justice in health care. Rawls himself never pursued these health-centered issues, but his theory has influenced many writers on moral problems of health and biomedical ethics, including Norman Daniels, Martha Nussbaum, and the team of Madison Powers and Ruth Faden.

Daniels argues that because health is affected by many social factors, theories of justice should not center entirely on access to health care, but also on the need to reduce health inequalities by improving social conditions that affect the health of societies, such as having clean water, adequate nutrition, and general sanitation.

Powers and Faden view the well-being of the worst-off members of global society as the proper starting point for a practical theory of justice, but their theory can also be expressed as an argument from social beneficence.

The sweep of global poverty and its impact on health and welfare is a major topic in the theories of Singer and Powers and Faden. Their theory also identifies unfair patterns of advantage and unfair relations of power such as subordination, exploitation, and social exclusion that are rooted in unjust social-structural conditions.

Among other things, their theory assesses the degree to which institutional structures can be expected to fulfill the mandates of the theory. This type of theory focuses on distributions intended to enable persons to reach certain functional levels essential for a flourishing life that is protected by social institutions.

The idea is to start with an understanding of health and individual well-being and then to connect that account to basic capabilities for achieving levels of functioning essential to well-being—through, for example, proper nutrition and access to health care. Some core capabilities are bodily health, ability to play, ability to affiliate socially, freedom of movement, and adequate educational level. Amartya Sen and Martha Nussbaum are advocates of a capabilities theory.

Some writers closely connected to bioethics and health policy have moved beyond capabilities theory with a twist toward beneficence and well-being. Powers and Faden provide a theory closely connected to global health policy. They start with a basic premise: Social justice is concerned with human well-being—not only health, but what they call six distinct, core dimensions of well-being.

The six are health, personal security, reasoning, respect, attachment, and self-determination. Each of these dimensions is an independent concern of justice. Theirs is a list of essential core dimensions of well-being, not core capabilities. Being healthy, being secure, and being respected are desirable states of being, not merely capabilities or functionings. For example, we want not merely the capability to be well-nourished, but to be well-nourished.

In this theory the justice and beneficence of societies and of the global order are to be judged by how well they effect these well-being dimensions in their political structures and social practices. The job of global justice and beneficence is to secure a sufficient level of each dimension for persons and to alleviate the social structures that cause the corresponding forms of ill-being. This theory of well-being and its place in moral theory and social policy can be expressed in terms of the roles of both social beneficence and social justice.

Business ethics is a second area of applied ethics in which questions about beneficence have emerged as central. Smith argued that the wealth of nations and the well-being of their citizens are dependent upon social cooperation—fundamentally, political and economic cooperation—but that this realm is not dependent on the benevolence of moral relations.

Smith proposes that it would be vain for us to expect benevolence in market societies. In commercial transactions the only successful strategy in motivating persons is to appeal to personal advantage: Never expect benevolence from a butcher, brewer, or baker; expect from them only a regard to their own interest. Market societies operate not by concerns of humanity and benevolence, but from self-love. Discussions of the role of the corporation in society and the very purpose of a corporation as a social institution are examples.

It is not disputed that the purpose of a for-profit corporation is to make a profit for stockholders, but there is an intense debate about whether maximizing stockholder profits is the sole legitimate purpose of corporations—as Milton Friedman and others have argued—and whether truly beneficent corporate conduct is justifiable.

This question is normative, but Smith also raises questions of moral psychology: Is it reasonable to expect benevolent acts from members of the business community? Does beneficence have any place in the world of business as we know it? Corporate social programs often appear to involve a mixture of limited beneficence and self-interested goals such as developing and sustaining relationships with customers.

These programs sometimes decrease rather than increase corporate profits. They are, in effect, a form of corporate philanthropy. The programs locate and attempt to remedy the root causes of bill nonpayment, which typically involve financial distress. The programs also seek to rescue people in the community who are in unfortunate circumstances because of industrial injury, the ill health of a spouse or child, drug dependency, and the like.

The company may even pay for consumer advocates, who are social workers trained to deal with customers and their problems. These programs, by design, make life better for various members of the community who have suffered misfortune. They may not be entirely motivated by benevolence, however, because they may be heavily designed to achieve a positive public image as well as to receive payment for overdue bills.

Some firms have charitable programs that seem to be cases of pure beneficence—that is, not ones admixed with forms of outreach that will help the company. Money is taken directly out of profits, with no expected return of benefits. It has been questioned, however, whether programs of even this description are instances of pure benevolence.

In the precedent U. Smith Manufacturing v. Barlow , a judge determined that a beneficent charitable donation to Princeton University by the A. Smith Co. However, the judge acknowledged that such beneficence may not be pure beneficence, but rather an act taken in the interest of the corporation by building its public image and esteem. In effect, the judge suggests that such a gift, while beneficent, may not derive from entirely benevolent motives.

Stakeholder theory answers in the affirmative. Who deserves to benefit from corporate income? A stakeholder is any individual or group that can affect or benefit, or be affected by or benefited by, a business organization.

Stakeholders who can be affected by corporate activities include customers, employees, suppliers, owners, local communities, subcontractors, consultants, and stockholders. Stakeholder theory is commonly regarded as a theory of corporate responsibility—the theory that managers of a firm have obligations to a specified group of stakeholders. Many of these obligations are ones of beneficence, especially with regard to employees and other stockholders.