Risk-Sensitive Assessment of Decision-Making Capacity: A Comprehensive Defense.

Should the assessment of decision-making capacity (DMC) be risk sensitive, that is, should the threshold for DMC vary with risk? The debate over this question is now nearly five decades old. To many, the idea that DMC assessments should be risk sensitive is intuitive and commonsense. To others, the idea is paternalistic or incoherent, or both; they argue that the riskiness of a given decision should increase the epistemic scrutiny in the evaluation of DMC, not increase the threshold for DMC. We respond to the critics' main concerns by providing a comprehensive account of how risk-sensitive DMC is coherent, avoids paternalism, and best fulfills the epistemic goal of DMC evaluations.

The phantasm of zero suicide.

Governments and non-governmental organisations are increasingly adopting a 'zero-suicide' goal, but what such a goal precisely involves is unclear. Ostensibly it strongly prioritises the prevention and elimination of all suicide. We argue that, so understood, a societal goal of zero suicide risks contravening several ethical principles. In terms of beneficence and non-maleficence, a 'zero-suicide' goal risks being inefficient and may burden or harm many people. Autonomy-wise, a blanket ban on all suicide is excessive. As regards social justice, zero suicide risks focusing on the symptoms of social malaise instead of the structures causing it. With respect to transparency, a 'zero' goal that cannot be met makes these authorities look detached and risks frustration, distrust and, worse, stigmatisation of suicide and of mental health conditions. Instead, we propose a middle path for suicide prevention, founded on harm reduction, 'soft group paternalism' and efforts directed at increased quality of life for disadvantaged groups. Although soft group paternalism respects autonomy, this approach permits coercive interferences in certain circumstances. We hope that the justificatory framework tying together these largely familiar elements is novel and sensible.

Could Behavioral Economics Mitigate Shortcomings in Shared Decision-Making?

While shared decision-making (SDM) is generally considered to be the standard in current clinical practice, strict application of SDM can result in adverse outcomes in certain contexts. This article examines two illustrative cases-antibiotic over-prescription and decision-making at or near the end of life-to highlight how strictly applied SDM can result in suboptimal outcomes. The article continues to describe how strategies from libertarian paternalism, particularly default setting, framing, and nudging, can be valuable tools in supplementing strict applications of SDM, resulting in improved outcomes and patient care on both individual and societal levels.

Physician outreach during a pandemic: shared or collective responsibility?

In 'Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?' Strous and Karni note that the revised physician's pledge in the World Medical Association Declaration of Geneva obligates individual physicians to share medical knowledge, which they interpret to mean a requirement to share knowledge publicly and through outreach. In the context of the COVID-19 pandemic, Strous and Karni defend a form of medical paternalism insofar as the individual physician must reach out to communities who may not want, or know to seek out, medical advice, for reasons of public health and health equity. Strous and Karni offer a novel defence of why physicians ought to intervene even in insular communities, and they offer suggestions for how this could be done in culturally sensitive ways. Yet their view rests on an unfounded interpretation of the Geneva Declaration language. More problematically, their paper confuses shared and collective responsibility, misattributing the scope of individual physician obligations in potentially harmful ways. In response, this reply delineates between shared and collective responsibility, and suggests that to defend the obligation of medical outreach Strous and Karni propose, it is better conceptualised as a collective responsibility of the medical profession, rather than a shared responsibility of individual physicians. This interpretation rejects paternalism on the part of individual providers in favour of a more sensitive and collaborative practice of knowledge sharing between physicians and communities, and in the service of collective responsibility.

A Values-Based Approach to Capacity Assessment.

The dominant approaches to assessing patients for decisional capacity in the clinical setting, the "four skills" and "sliding scale" models, emerged in the 1970s and 1980s against a backdrop of medical paternalism and reflect their origins in law and forensic psychiatry. They privilege rationality and require the ability to defend one's decisions with knowledge and argument. Unfortunately, these approaches place a heavy burden upon patients who may hold preferences consistent with their underlying values but may not possess the education or reasoning skills necessary to meet the heavy burden imposed by current capacity standards. This article reviews the shortcomings of the dominant models. Then the article proposes a novel value-based approach to capacity assessment that places primary emphasis upon the patient's underlying and longstanding values and the concordance of those values with the patient's current wishes and preferences.

Collateral Paternalism and Liberal Critiques of Public Health Policy: Diminishing Theoretical Demandingness and Accommodating the Devil in the Detail.

Critical literatures, and public discourses, on public health policies and practices often present fixated concerns with paternalism. In this paper, rather than focus on the question of whether and why intended instances of paternalistic policy might be justified, we look to the wider, real-world socio-political contexts against which normative evaluations of public health must take place. We explain how evaluative critiques of public health policy and practice must be sensitive to the nuance and complexity of policy contexts. This includes sensitivity to the 'imperfect' reach and application of policy, leading to collateral effects including collateral paternalism. We argue that theoretical critiques must temper their demandingness to real-world applicability, allowing for the detail of social and policy contexts, including harm reduction: apparent knock-down objections of paternalism cannot hold if they are limited to an abstract or artificially-isolated evaluation of the reach of a public health intervention.

Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?

A recent update to the Geneva Declaration's 'Physician Pledge' involves the ethical requirement of physicians to share medical knowledge for the benefit of patients and healthcare. With the spread of COVID-19, pockets exist in every country with different viral expressions. In the Chareidi ('ultra-orthodox') religious community, for example, rates of COVID-19 transmission and dissemination are above average compared with other communities within the same countries. While viral spread in densely populated communities is common during pandemics, several reasons have been suggested to explain the blatant flouting of public health regulations. It is easy to fault the Chareidi population for their proliferation of COVID-19, partly due to their avoidance of social media and internet aversion. However, the question remains: who is to blame for their community crisis? The ethical argument suggests that from a public health perspective, the physician needs to reach out and share medical knowledge with the community. The public's best interests are critical in a pandemic and should supersede any considerations of cultural differences. By all indications, therefore, the physician has an ethical obligation to promote population healthcare and share medical knowledge based on ethical concepts of beneficence, non-maleficence, utilitarian ethics as well as social, procedural and distributive justice. This includes the ethical duty to reduce health disparities and convey the message that individual responsibility for health has repercussions within the context of broader social accountability. Creative channels are clearly demanded for this ethical challenge, including measured medical paternalism with appropriate cultural sensitivity in physician community outreach.

The Engaged Patient: The Relevance of Patient-Physician Communication for Twenty-First-Century Health.

The patient-doctor interaction has changed profoundly in the past decades. In reaction to paternalistic communication patterns, health policy makers have advocated for patient-centered care and shared decision-making. Although these models of medical communication remain still aspirational, patients have become more engaged in advocating for their own health in encounters with physicians. I argue that the engaged patient is a more accurate conceptualization of the changing role of the patient than patient consumerism, the empowered, or expert patient. I examine how the emergence of engaged patients influences the autonomy of health professionals, relates to the rise of the internet as an alternative source of medical information, centers the role of the patient-doctor interaction in public health epidemics, and contributes to health inequities.

Six Propositions against Ageism in the COVID-19 Pandemic.

The risk of developing severe illness from COVID-19 and of dying from it increases with age. This statistical association has led to numerous highly problematic policy suggestions and comments revealing underlying ageist attitudes and promoting age discrimination. Such attitudes are based on negative stereotypes on the health and functioning of older adults. As a result, the lives of older people are disvalued, including in possible triage situations and in the potential limitation of some measures against the spread of the pandemic to older adults. These outcomes are unjustified and unethical. We develop six propositions against the ageism underlying these suggestions to spur a more adequate response to the current pandemic in which the needs and dignity of older people are respected.

The Opportunity Cost of Compulsory Research Participation: Why Psychology Departments Should Abolish Involuntary Participant Pools.

Psychology departments often require undergraduates to participate in faculty and graduate research as part of their course or face a penalty. Involuntary participant pools (human subject pools) in which students are compulsorily enrolled are objectively coercive. Students have less autonomy than other research participants because they face a costly alternative task or the penalties that accompany failure to meet a course requirement if they choose not to participate. By contrast, other research participants are free to refuse consent without cost or penalty. Some researchers claim that the educational value of participation justifies the requirement. They treat coercion as a cost that can be outweighed by the benefits to students. This paper argues that such an approach is flawed because coercion is not like other costs and that educational value is inherently low relative to personal study or classroom time. The unethical nature of involuntary participation is best demonstrated with an opportunity cost analysis. This shows that students are forced to sacrifice higher value alternatives that they have paid to do and undertake a lower value activity that principally benefits others. Faculty have a conflict of interest as they are the beneficiaries of student coercion in their role as researchers and responsible for student achievement in their role as teachers. Voluntary participant pools can resolve this conflict but at the cost of reducing the supply of participants. A change in departmental research conduct is required to restore the autonomy of students who are competent adults and not legitimate subjects of paternalism when it comes to research participation.

Decisional autonomy undermines advisees' judgments of experts in medicine and in life.

Over the past several decades, the United States medical system has increasingly prioritized patient autonomy. Physicians routinely encourage patients to come to their own decisions about their medical care rather than providing patients with clearer yet more paternalistic advice. Although political theorists, bioethicists, and philosophers generally see this as a positive trend, the present research examines the important question of how patients and advisees in general react to full decisional autonomy when making difficult decisions under uncertainty. Across six experiments (N = 3,867), we find that advisers who give advisees decisional autonomy rather than offering paternalistic advice are judged to be less competent and less helpful. As a result, advisees are less likely to return to and recommend these advisers and pay them lower wages. Importantly, we also demonstrate that advisers do not anticipate these effects. We document these results both inside and outside the medical domain, suggesting that the preference for paternalism is not unique to medicine but rather is a feature of situations in which there are adviser-advisee asymmetries in expertise. We find that the preference for paternalism holds when advice is solicited or unsolicited, when both paternalism and autonomy are accompanied by expert guidance, and it persists both before and after the outcomes of paternalistic advice are realized. Lastly, we see that the preference for paternalism only occurs when decision makers perceive their decision to be difficult. These results challenge the benefits of recently adopted practices in medical decision making that prioritize full decisional autonomy.

The Social Construction of Incompetency: Moving Beyond Embedded Paternalism Toward the Practice of Respect.

This article illustrates the less-acknowledged social construction of the concept of 'incompetency' and draws attention to the moral concerns it raises in health care encounters in the south Indian city of Chennai. Based on data drawn from qualitative research, this study suggests that surgeons subjectively construct the idea of incompetency through their understanding of the perceived circumstantial characteristics of the patients and family members they serve. The findings indicate that surgeons often underestimate patients and family members' capacity based on constructed assessments, which leads to paternalistic practice. In this article, I illustrate how these assessments influence the surgeons' practices and provide the moral and practical justifications for their actions. The constructed knowledge becomes a source for drawing normative justification for surgeons' actions and, in conjunction with socially enforced power relationships, results in patients and family members to be on the receiving end of disrespectful attitudes. Based on the data analysis and by drawing on philosophical analysis, I emphasize the need to focus on 'respect for persons,' to rethink the framework of 'capacity,' and to practice respect in hospital settings.

Development and validation of a paternalism and autonomist care assessment.

AIM: There is a need for a validated instrument to measure the type of care (paternalism or person-centred) provided for older adults. Since paternalism and person-centred care are the most important caregiving styles in the field of care and as they are usually opposed, the study aims to develop and establish psychometrics data of an instrument to identify paternalistic and autonomist behaviours in older adults care contexts, which can help to enhance care practice. DESIGN: Instrument development. METHODS: After observing and standardizing behaviours in formal care contexts in 2016, an instrument was developed and proceeding to a first validation using standard validation techniques among caregivers in two care settings during 2016-2017: senior citizen centres and older adult day care centres. RESULTS: The Paternalist/Autonomist Care Assessment (PACA) is a 30-item, behaviour-based instrument which measures both the appraisal of caregivers on elements of care (Care Appraisal Scale- PACA-Appraisal) and the occurrence of behaviours (Occurrence of Care in Context- PACA-Occurrence). The Paternalist/Autonomist Care Assessment (PACA) was validated in 160 professional caregivers and was able to discriminate two factors: paternalistic or overprotective behaviours and autonomist behaviours. However, these factors were not fully dichotomous and were shown to coexist to some degree. CONCLUSION: The instrument displayed good psychometric properties to measure paternalism and autonomy in older adult care. Moreover, it showed that the two types of care are not antagonistic and can coexist, with overprotective behaviours being more frequent in contexts of care for more dependent persons. IMPACT: There are no validated instruments to measure paternalism and person-centred behaviour in care contexts. The two measures yielded by the PACA show good construct and concurrent empirical validity, internal consistency, and convergent and discriminant validity. Family caregiver, professional caregivers, nurses, older adults.

When the Hospital Is No Longer an Option: A Multiple Case Study of Defining Moments for Women Choosing Home Birth in High-Risk Pregnancies in The Netherlands.

Some women in a high-risk pregnancy go against medical advice and choose to birth at home with a "holistic" midwife. In this exploratory multiple case study, grounded theory and triangulation were employed to examine 10 cases. The women, their partners, and (regular and holistic) health care professionals were interviewed in an attempt to determine whether there was a pattern to their experiences. Two propositions emerged. The dominant one was a trajectory of trauma, self-education, concern about paternalism, and conflict leading to a negative choice for holistic care. The rival proposition was a path of trust and positive choice for holistic care without conflict. We discuss these two propositions and make suggestions for professionals for building a trusting relationship using continuity of care, true shared decision making, and an alternative risk discourse to achieve the goal of making women perceive the hospital as safe again.

Can Physicians Demonstrate High Quality Care Using Paternalistic Practices? A Case Study of Paternalism in Latino Physician-Patient Interactions.

We argue that patient autonomy is a cultural value specific to Western culture and that the autonomy focus in U.S. health care may produce negative patient outcomes for patients from other cultures. To this end, we present a case study of a Mexican physician's interactions with his patients and apply the method of discourse analysis to argue that (a) this physician's interactions are highly paternalistic, (b) there is an appreciation for this among his Latino patients and in the broader Latino community, and (c) this physician provides high-quality ethical care precisely because his paternalism communicates important ethical values such as familial intimacy, insistence, and care. We further propose that paternalism may produce better outcomes for Latino patients.

A New "Shield of the Weak": Continued Paternalism of Domestic Violence Services in Uruguay.

Drawing on ethnographic and historical research, this article illuminates the limitations of the Uruguayan domestic violence services system. In spite of how advocates in Uruguay successfully used a human rights platform to secure legislation and services, this system now faces significant critique. Using Iris Marion Young's work on the "logic of masculinist protection" and historical parallels in Uruguay's welfare system, I discuss how a paternalistic approach may be to blame. I highlight how this paternalism contributes to the paternalism that problematically underlies gendered violence-reinforcing rather than addressing oppressive ideologies and structures that impede improving conditions for women.

"Right to recommend, wrong to require"- an empirical and philosophical study of the views among physicians and the general public on smoking cessation as a condition for surgery.

BACKGROUND: In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as well as the reasons provided for this. METHODS: A random sample of general practitioners and orthopaedic surgeons (n = 795) as well as members of the general public (n = 485) received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. RESULTS: Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. CONCLUSIONS: There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a "recommendation strategy" vis-à-vis smoking cessation prior to surgery rather than a "requirement strategy". The normative reasons speak in favour of the "recommendation strategy".

When doctors deny drugs: Sexism and contraception access in the medical field.

Politicians, employers, courts, and health insurance companies are often discussed as problematically preventing access to birth control. However, doctors have more direct control over women's health and quietly have been much more effective at preventing patients' access to contraception. Obstetrician/Gynecologists routinely deny their patients access to contraception ostensibly in the name of health by withholding birth control until patients undergo yearly pap smears. I argue that those in the medical field are motivated by similarly sexist concerns as those in other major institutions in the United States, but that they are often overlooked in discussions of biomedical ethics. After providing background, I argue that using birth control as a bargaining chip to control patients is morally impermissible, is paternalistic, and is contrary to consent. I next argue that sexism explains, though does not justify, this practice. I discuss the medical harms of routine pap smears and withholding birth control. These claims make medical malpractice likely. Withholding birth control to coerce individuals seeking medical care is medical malpractice, paternalistic, violates autonomy, and is contrary to consent.

Endogenous versus exogenous generic reference pricing for pharmaceuticals.

In this paper we carry out a vertical differentiation duopoly model applied to pharmaceutical markets to analyze how endogenous and exogenous generic reference pricing influence competition between generic and branded drugs producers. Unlike the literature, we characterize for the exogenous case the equilibrium prices for all feasible relevant reference prices. Competition is enhanced after the introduction of a reference pricing system. We also compare both reference pricing systems on welfare grounds, assuming two different objective functions for health authorities: (i) standard social welfare and (ii) gross consumer surplus net of total pharmaceutical expenditures. We show that regardless of the objective function, health authorities will never choose endogenous reference pricing. When health authorities are paternalistic, the exogenous reference price that maximizes standard social welfare is such that the price of the generic drug is the reference price while the price of the branded drug is higher than the reference price. When health authorities are not paternalistic, the optimal exogenous reference price is such that the price of the branded drug is the reference price while the price of the generic drug is lower than the reference price.