1. Science and technology raises ethical issues, particularly issues of how medical
advances get used to impact human well-being and health.
2. Treatment decisions fit a very specific decision of how we determine whether medical
advances serve human beings or not. Who is able to make the key medical decisions?
3. Who Should be Making the Treatment Decisions?
a. Some argue that the doctor should make the decisions, due to his medical
b. Some argue that the patient should be in the driver’s seat, because only he or she
knows his own beliefs and values, and can make the choice of whether or not
treatment, or tests, outweigh the risks and the harms.
c. Some argue that the insurance companies and governments that offer healthcare
determine the treatments, because they have to pay, and must determine whether
any decisions are unnecessary. They sometimes give clinics and hospitals specific
guidelines to determine whether medical aid should be given, in order to
a. Paternalism – When one person or institution makes decisions for other people,
independently of those others’will or choice, but for their good.
i. Under what conditions is paternalism justifiable, or unreasonable,
oppressing liberty, etc.?
1. E.G. Parents who expect to make decisions for children, for their
own good.Adecision made by the parents independent of the will
of the child, for the child’s own safety.
2. E.G. Seatbelt law: “Click it or ticket.” There are, however, people
who prefer not to, but would not end up better off if in an accident.
Many people do not want to wear motorcycle helmets either. No
beer, or alcohol in the dorms, or in the campus. This is all for
YOUR own good, so these laws are paternalistic. They put these
regulations behind rules that some people may not want to follow.
ii. Where an adult is incompetent or unable to make decisions for
him/herself, other people should be able to make decisions for them.
b. Medical Paternalism – Who should be making the treatment decisions? Mainly
the doctor, because he has the medical expertise to know your condition, and
decide what the best treatment option is. Independently of the will of the patient,
but for the better health of the patient.
i. This is not an ideology of doctors. This is a doctrine. ii. The doctor makes the decision of what information is told to the patient.
Sometimes information is withheld from the patient in order to prevent the
scaring of the patient, and the minimum information may be given simply
in order for the patient to follow orders.
iii. Medical paternalism justifies, under some circumstances, the withholding
of information, even deception.
c. Goldman does two things:
i. Gives the argument for medical paternalism, including the reasons that
people demand or expect medical paternalism.
1. Made on two premises:
a. Every doctor has one and only one goal for medical
treatment: health, the only and dominant goal of every
doctor and patient in situations of health and care, including
preventing disease, minimizing the toll of disease and
b. The doctor, not the patient, has the knowledge and skill to
make effective the means to this goal.
c. Therefore the doctor should be making all the decisions.
ii. Goldman refutes the argument, in that the reasons do not justify the
1. He criticizes the argument, rejects medical paternalism, and
defends the principle of patient’s choice, and the right of patients to
know their diagnosis and decide from all the treatment of options
(the benefits and risks, etc) including no treatment as an option.
a. The first premise is false: health is not the single, sole
dominant value in doctors and patients. Rational patients,
despite being primarily concerned with their health, bring
other preferences and desires to the medical situation that
are affected, for better or worse, by the course of treatment,
and by what they are told by the doctor. Without the
patient, or the doctor knowing these preferences, there is no
such thing as an effective treatment.
2. Goldman implies (but does not argue) that in these areas, where
you are faced with multiple options and choices, the concept of
cost-benefit analysis comes to play. The most rational choice is the
one that brings in the most benefits, and decreases the risks the
most. What are the benefits and risks of each treatment option? d. What is health?
1. Restoration of normal function and the quality of life
2. The continuity of existence (protection of the risk of death)
3. Reduces pain
ii. The term of “health” is often considered to be one unified term, but when
these individual components are a focus of ethical issue, in that these goals
may conflict each other, then that is when an ethical decision must be
iii. E.G. Apatient is placed under a vegetative state. There are three goals of
health, reducing pain, the restoration of the quality of life, and preventing
death, and these come into conflict.An attempt can be made to restore
functionality, but pain will be involved. The pain can be ended, the
patient’s life ended, but at the conflict of preventing death. What is the
right treatment option? Depends on the patient’s values and preferences.
1. It is entirely impossible for the doctor to make a decision that
completely satisfies the patient’s values, and the values of the
concept of health simultaneously.
e. From Goldman’s point of view, anytime a doctor is involved, there will be
benefits and risks involved. The most effective treatment for one particular patient
may not be the same with that of another patient, based on the different values of
the different patients.
i. E.G. Evidence of lumpectomy curing a particular disease, and is as
effective as radical mastectomy, but not as disfiguring. However, doctors
still recommend radical mastectomy even though lumpectomy was a real
and reasonable choice. Radical mastectomy patients had a lower chance of
remission. In the sense of Goldman, there was a choice between patients.
Some women may be concerned with their physique, and others may be
concerned primarily with health. Those pushing for radical mastectomy
thought they were acting on the basis of the interest of the woman.
1. Oncologists in this field knew the evidence of lumpectomy, but
they were taught radical mastectomy, and thus put their trust into
that practice, and endorsed their patients to do so as well. They
behaved based on old data.
2. The evidence was that lumpectomy was effective, but not proven
to be as effective as a radical mastectomy. 3. These two treatments affect different values of a patient’s life, such