Paternalism and Its Relation to Health Promotion, Research Paper Example

Synopsis

This paper discusses the issue of paternalism in relation to public health promotion. Various perspectives of paternalism have been provided after having defined it, providing its nature as well as its relationship to autonomy and beneficence which are the main arguments of this paper. Further, types of paternalism have been explained based on their extent of consequences. Further on, the critique of paternalistic practices in medicine has been provided. Later, health promotion and public health have been defined and explaining how paternalism is related to them. Firstly, soft paternalistic practices within health promotion have been defended given that they are aimed at welfare of not only individuals but public at large. After that, instances of paternalistic practices in health promotion have been provided followed by ethical priorities of paternalism in respect of health promotion. Furthermore, limitations of paternalism in respect of health promotion have been provided where paternalism has been criticized with emphasis on autonomy and respect of libertarian rights of individuals. The paper concludes with the partial support to paternalism given that it supports public health at large, while also recommending that information sharing is crucial for minimizing legal and ethical implications.

Introduction

This research paper is centred on one of the major debates in today’s clinical practice, i.e. paternalism and how it is related to health promotion. Given the ethical dilemma involving paternalistic practices, various practitioner and scholarly works have been reviewed to focus on the importance of the ethics involved in paternalism and to what extent it can be justified as practised with the motive of promoting health even though that might violate civil liberties and rights of individuals.

Considering that paternalistic practice in health promotion is aimed at the welfare of the larger communities and not just at the individual level, the justification for the same has been provided. Further, various arguments in favour of and against paternalism have been presented to articulate the current status of paternalistic practices and their ethical stature within medical practices.

The Nature of Paternalism

In a study in 1961 it was revealed that 88% of doctors would not tell their patients of a diagnosis that suggest a terminal illness such as cancer. This is argued on the premise of therapeutic privilege where doctors are at liberty to decide for their patients by virtue of an argument that suggests that it is in the patient’s best interest to conceal some of their personal records on the belief that it will do more good for the patient (Duncan) Does it need page number) This book is not listed in the reference list and Duncan is my tutor!. This is the main contention of paternalism. However, critics (Campbell et al., 2005) argue that this is not in the best interest of the patient because by doing so, the doctors are depriving the patients of making the necessary decisions concerning their own health. Thus, critics see the conflict of paternalism with the principles of autonomy. Respect for autonomy is identified as an important facet of the doctor-patient relationship and by practicing the principle of paternalism, the doctors are showing clear disregard of maintaining this relationship (Campbell et al., 2005).

Paternalism in health is understood in two perspectives. One aspect of paternalism is viewed as a manner or way of (1) protecting the patient from their own self for making irrational decisions and (2) protection against incompetent family members, friends and guardians (Lowenstein et al., 2007). On the other hand, the other aspect of paternalism is seen as something that violates the rights of the patient from being self-sufficient and from exercising autonomy over his own well-being. In addition, paternalism is seen as something bad because of the argument that it is unethical to keep the patient in the dark of their real condition. By doing so, a patient might be exposed to a bigger risk given that he is kept unaware of what to avoid and what must be done to make one self-better (Moser-Jones & Bayer, 2007).

Defining Paternalism

The concept of paternalism was taken from the Latin word pater meaning “father.” However, careful interpretation of the word must be ensured so as not to misrepresent paternalism with the concept of patriarchy (Cribb & Duncan, 2002). This idea of paternalism could be related to the fact that fathers have the authority over their children and can direct the latter’s action according to the father’s dictate. Thus, paternalism can be interpreted from the premise that fathers have the authority to make the decision for their children on the argument that being a father, he has the innate power to do so given that fathers have the better judgment by virtue of their experience, their authority and their knowledge (Cribb & Duncan, 2002).

The same principle operates in the medical profession where doctors can perform their therapeutic privilege in defence of promoting the health of the patients which serves the latter’s best interest. In defence, the doctors argue that above all other people they have the better capacity in terms of knowledge and interest for warranting a decision in behalf of their patients. Now, these arguments are all founded upon the logical perspective of the concept of paternalism (Doxiadis, 1987). The modern interpretation of paternalism in the light of a political perspective would stress the role of key terminologies. By virtue of its political nature, paternalism is defined as the behaviour of a person, state or organization that restricts another person to fully exercise his right over his own good (Dworkin, 2010). However, other interpretation of the word expresses a strong emphasis on the ground that this restriction or interference by a person, state or organization is against the other person’s will. Therefore, paternalism is viewed as a violation or way of curtailing the right of another person by virtue of a law, norm or standards (Doxiadis, 1987).

In the realm of the political basis of paternalism, it is believed that in a democracy there is no room for this practice. Democracy adheres to the belief that an individual has the right to govern himself—his words, thoughts and actions (Doxiadis, 1987). Considering that democracy emphasizes on autonomy and individual liberty of a person, paternalistic practices seem unethical in democracies, especially when the individual subjected to paternalism are capable of cognitive senses and decision making. The definition of the concept of paternalism all revolves around the premise that an individual, organization or state has the right to interfere with other people’s affair on the argument that it is in the best interest of the other person (Dworkin, 2010).

Paternalism, Autonomy and Beneficence

In analysing the principle of paternalism in medical ethics, the concept of autonomy and beneficence could not completely be disregarded. While paternalistic approach has taken a root in the medical profession, the modern practice of medicine has been aware of the abuse of this practice. Autonomy allows for self-determination and liberty. However, paternalism is always seen to be in conflict with autonomy and beneficence. To understand these concepts, it is best to give meaning to each term. Hence, the above stated concepts are defined as follows:

1. Paternalism: Paternalism can be defined as the behaviour of person, organization or state that limits an individual’s liberty or autonomy for their good which can be against the latter’s will (Dworkin, 2010). Paternalistic practices emphasize on intervening an individual’s liberty or autonomy often against the individual’s will, however the action endorsed by paternalism are directed at the welfare of the individual or the society at large.
2. Autonomy: According to Deci & Ryan (2002), autonomy is state of functioning independently without the interference by others and personal limitations preventing meaningful choices. In other words, autonomy is the capacity of a rational individual to make an informed, un-coerced decision.
3. Beneficence: According to Tauber (2005), beneficence can be regarded as the performance or act of active goodness or charity, including all actions intentionally done to benefit others. Beneficence pertains to actions that promote the well-being of others.

Paternalism has already been explained in the previous pages but for the sake of showing the correlation of the three concepts, the author will give the interpretation of paternalism in the realm of medical ethics. Due to the argument that paternalism gives the doctors the right to decide for the patient by virtue that it is for the patient’s best interest, it is otherwise seen as an arrogant assertion that doctor’s know everything, including predicting the patient’s emotion and behaviour (Campbell et al., 2007). Power plays a significant role in this subject considering that the doctors have the superiority over their patients in terms of education, the scope of knowledge in reference to the patient’s condition and the possession of having known the available options for the patient. Oftentimes, this advantage of the physician over the patient may result to an imbalance in the doctor-patient relationship. The reference here is the above Campbell et al?

There are still several types of paternalism in the medical profession according to normative view. The legalities and the moral justification of a certain type of paternalism depend on the terminologies used. Based on the extent or the degree, to which paternalism is practised in medicine, there are four varieties as stated by (Sheffrin, 2000):

1. Soft Paternalism: Allows the protection of an individual from harming self if the act is substantially involuntary I didn’t understand the meaning here (Sheffrin, 2000). Elaborating further, the author also observes that if the act is voluntary, only temporary intervention is necessary. Soft Paternalism seems morally acceptable since it does not impose anything to the patient.

2. Hard Paternalism: Advocates coercion to protect adults against their voluntary self-harming choices (Sheffrin, 2000).
3. Weak Paternalism: Practiced assuming that the patient is unable to understand the medical information, this the doctor decides in the patient’s best interest (Sheffrin, 2000). The above author also states that weak Paternalism is more acceptable because the patient voluntarily submits to the doctor’s decision because of the belief that the doctor is credible to make the right judgment.
4. Strong Paternalism: In this type of paternalism, there exists the intentional interference of the patient’s wish either openly or through deception (Sheffrin, 2000).

Autonomy and beneficence are sometimes compromised with the irregularities in maintaining this type of paternalistic relationship {which type of relationship?}in the hospital setting (Hope et al., 2008). This is because paternalistic doctors would always assert that they are after the patient’s best interest in warranting their decisions. On this argument, the best defence is through the use the argument of John Stewart Mill (Mill 1859 in Hope et al 2008 P.41) when he defended this libertarian principle. According to Mill (Mill 1859 in Hope et al 2008 P.41), if a person, an organization or a state would like to impose its own decision upon another person, the simple argument that is actually for the other’s best interest would not be enough, neither is it justifiable.

Autonomy refers to one’s right to self-determination. This is the belief that a person is wholly capable of making rational decisions on personal affairs. The relevance of this principle in the medical profession has stressed the significant role on the individual’s capacity to render sound judgment on matters that concern their own self rather than relying heavily on the decision of health professionals. This is seen as a reaction towards the practice of paternalism in the medical profession which is contradictory to medical ethics. However, there were some points being raised that autonomy has withdrawn the proper application of soft paternalism that could somehow benefit other patients for whom the concept of soft paternalism has been proven effective (Jackson, 2009).

Critique of medical paternalism

Within ethics and with emphasis on medical ethics, the principle of autonomy seems very important for every argument. In this respect, (Duncan, 2010) opined that autonomy secures a patient’s liberty and right of self-determination. Here, there is clear contradiction between autonomy and the principle of paternalism, which within medical practice is used to make “assumptions of decision making as against the patient’s discretion and choice”, often without the patient’s knowledge, as also opined by (Campbell & Jones, 2005). The assumption that the doctor knows what is best for the patient is emphasized within paternalism in clinical practice.

One important argument within the debate between paternalism and autonomy is that there power imbalance between a patient and his/her doctor. Due to the fact that the doctor or healthcare professional is in strategically higher power status, sanctions the assumption to practice paternalism. Hence, the patient-doctor relationship has come into the light of ethical argument to consider such imbalance. Thus, there is a need for such relationship between doctors and patients to be administered with code of ethics (Wolff, 2011). Within the paternalism argument, in case, if the patient is not educated enough the imbalance is likely to be exemplified wherein the patient is at the mercy of the doctor’s discretion and decisions. When the patient is not educated and has negligible knowledge of the treatment, the doctor is in a higher level of discretion due to the existence of disparity between their relationships. Thus, the patient being in a lower level in the relationship balance makes his/her state vulnerable until and unless the healthcare professional does not exploit the patient’s condition. Thus, it is the responsibility of the doctors to reduce the identified imbalance to the extent possible in order that the patient receives the best possible care under his/her decisions and discretion for which patient education is essential (Melia, 2004).

Paternalism can be criticized considering the ethics of libertarianism. In this respect, the following criticism was presented within the work of (Hope et al., 2008):

“The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. Patient’s own welfare, either physical or moral, is not a sufficient warrant”-(Mill 1859 in Hope et al 2008 P.41). Hence, the decisions of healthcare professionals should not be paternalistic by not considering the personal liberty and autonomy of patients.

Moreover, (Melia, 2004) maintained that paternalistic practices in medicine can lead to abuse in cases there is no proper administering with huge imbalance in power leading to exploitation of the patient’s condition. Hence, power of autonomous decisions should be entrusted to doctors and professionals with sufficient experience. Thus, the major criticism of paternalism lies in the argument of power exploitation more in vulnerable patient-doctor relationships. The conventional paternalistic approach is outdated due to the fact that it keeps the patients virtually ignorant of their treatments and related decisions. Thus, such rejection of the old paternalistic approach will give scope for resolving the identified imbalance in the relationships between doctors, patients and other healthcare professionals (Melia, 2004). Hence, such imbalance can be resolved by empowering the patients with the granting of their liberties for intervening in the decisions made with regard to their treatment.

Health Promotion and Public Health

Within the purview of health promotion, the involved ethical issues are numerable and complex given its sophisticated scenario. According to (Van der Maesena et al., 2000), the issues within epidemiology, i.e. the public health issues, prompt for health promotional activities. Thus, elaborating further, this section is dedicated to the discussions on the ethical concerns within health promotion related to public health. First, we begin with the definition of health promotion:

Defining Health Promotion

According to (Van der Maesena et al., 2000), contemporary health promotion is a “process of enabling people to increase control over and to improve their health, with health generally accepted as not just the absence of disease but also a major resource for life, a basic human need”. Hence, health promotion is not confined to just controlling the disease but to ensure that health is a fundamental requisite for every human. In the above definition, one must note that health promotion, from its erstwhile definition and perception, has undergone a vast change.

Relation of Health Promotion to Public Health

Generally, as also noted by (Kass, 2001), health promotion derives its prominence from epidemiology which identifies the issues which require health promotional activities. However, (Duncan, 2007) disagreed to the above contention by stating that in the present scenario health promotion does not always depend on epidemiology for direction. Moreover, the traditional epidemiological methods are outdated to meet the current health promotion demand and its complex scenarios involving complicated health issues. In this respect, (Gillon, 1990) opined that the current public health issues are not only complicated but multi-factorial.

In respect of health promotion, (Van der Maesena et al., 2010) observed that health promotional activities should identify ill social conditions and improve on them to mitigate the possibility of disease development to the surrounding lives. Hence, by working for development of better social surrounding, public health issues are mitigated and health promotion does not need to be dependent on epidemiology anymore (Jackson, 2006). For instance, the decreasing rate of tuberculosis is attributed not to the epidemiological therapy measures but to the improved living environment resulting from health promotional activities (Melia, 2004).

Now, the question of how ethical dilemmas such as paternalism and autonomy are applied within health promotion comes into light. Given that health promotion needs to be established certain ethical considerations are adopted. Within health promotion the ethical inclination such as paternalism are implemented adhering to least infringement of individual rights. The objectives of health promotion are to enhance health by enhancing the environment and surroundings of people’s settlement and hence ethical contradictions are likely to arise. Reference here?

The purpose of health promotion is also to enhance personal hygiene of people to contribute to better health at the personal level for which civil liberties might be ignored accounting for ethical contradiction (Seedhouse, 2009). For instance, the drink-driving limit lays restriction on an individual’s choice to take alcoholic drinks. However, considering that consuming alcohol and driving is a threat to society, restrictions can be laid down against an individual’s choice to drink and drive. Furthermore, (Seedhouse, 1997) stated that the issues like tobacco smoking disproportionately impact the poor communities within an economy; hence, smoking bans are justified in this respect, as also observed by Doxiadis, 1987). I didn’t understand the meaning here

In cases such as those described above, health promotion alone cannot fulfil the purpose of creating awareness and proposing remedies. Moreover, health promotion is at stake ethically if it were to implement activities that are biased towards a particular group or case inevitably breaching civil liberties. Here, (Doxiadis, 1990) observed that health promotional activities that are biased in nature are likely to be major social arguments involving ethical considerations. According to the above author, more often than not, ethical dilemmas arise due to not focusing on the cause of the problem, especially with regards to health promotion. Hence, health promotion given its paramount usefulness for public should justified by such public without which health promotion remains ethically invalid. The core objectives of health promotion should be to promote health at the personal and public levels to promote the welfare of the people ultimately. Here, (Doxiadis, 1990) remarked that if health promotion is aimed at mitigating societal harm, the actions of which are ethically considerable and legally binding, breaching autonomy can be justified.

However, in the case where there is dis-proportionality, (Duncan & Cribb, 1996) argued that justifying autonomy breaching can be considered upon weighing that “prevention is better than cure”, within which the cure part is likely to be costly to the economically backward communities. As for instance, emphasizing on control of alcohol consumption amongst the working class, health promoters would like to take up awareness campaigns for the working class citizens under the assumption that prevention is more important in such instances. However, the efforts to mitigate alcohol and other intoxicating drugs production were not emphasized (Tauber, 2005). Hence, paternalism cannot be justified; rather healthcare authorities should work towards controlling the production because the source of harm has to be removed and not by controlling those who become victim to it upon their own discretion.

Hence, in the above instance health promotional activities require public justification which can be acquired given the weight of the cause for which those activities are taking place. Given that the medical practices have established ethical standards, public justification of practices should be put into provisions to enhance living standards through essentials such as health promotion for public health. Here, (Fitzpatrick, 2008) observed that such commonly accepted standards should be implemented in order to implement health promotion.

Over the years, researchers in clinical research have been trying to justify health promotion by scientific evidence. Furthermore, researchers have been reporting that health promotion is seldom harmful with negligible failure rates (Fitzpatrick, 2008). In this respect, (Seedhouse, 2009) observed that reviews as well as control trials have been providing sufficient evidence for health promotion. However, (Fitzpatrick, 2008) opined that the conventional trials using quantitative analysis cannot be relied upon for providing good evidence for health promotion and also quantitative analysis cannot provide proper understanding. On the other hand, (Williams, 1986) have suggested that qualitative paradigms can be more effective when combined alongside quantitative for providing sufficient evidence in respect health promotion’s contribution to improvement of health both at individual and community levels. Thus, the assessment of health promotional benefits relies on the chosen method of analysis, which is best recommended to be a combination of both qualitative and quantitative. Having seen various scenarios within health promotion bringing forth the ethical concerns involved, the author observes that there are innumerable attributes of health promotion that have not been addressed here.

The reason for versatile attributes involving ethics is due to the fact that health issues in common are multi-factorial requiring health promotional activities to be multi-faceted to meet those diverse scenarios. The already existing code of ethics justifies health promotion which is directly under its purview, thus professionals of health promotion have their roles ethically justified. However, certain minor breach of autonomy should be articulated as justified action provided such action is directed at promotion of health and welfare of the public. Thus, the end results of health promotion should be considered for ethical justification health promotion aimed at enhancing public health (Tauber, 2005).

In Defence of Paternalism in Promoting Health

On several arguments defending paternalism, the best defence had been presented several decades ago in the person of John Stewart Mill (Mill 1859 in Hope et al 2008 P.41). On his argument he said that to get the approval of any civilized society to surrender the decision of their personal affairs to another person, organization or state, the concerned practitioner whether in public health or medicine should make an appeal to get support in grounds that his/her actions is intended for welfare of the public or an individual. In this case, the society will see the act as something noble instead of arguing that the interference is done because one is of better judge than the person himself. For instance, banning drinking and driving will help prevent accidents which are not aimed at safeguarding the health of the concerned individual but the health concerns of large audience. However, there were several issues that had been pointed out referring to the definition and the moral liabilities attached to the concept of paternalism.

One point being raised is what actually warrants the use of the phrase “in the best interest” of the public. Here, (Lim, 2002) mentioned that as the public health decision making is taken by governmental bodies arguments of health of large audiences are preferred even if they meant barring individual rights and autonomy. The argument is for a larger benefit even if it meant curtailing rights at the individual level. For instance, recently electricity supply to a poultry farm in a village in India was curtailed on public appeal that it caused nuisance due to heavy stinking. The incident saw the death of almost 8, 00,000 hens which died instantly in air conditioned chambers due to shortage of electricity supply. In the above incident the health of the public was given preference, however, it caused the death of large number of hens which is arguably not a justified act. Instead, it would have been good if the owners of the poultry were asked to move away from the village which can justified in terms of soft paternalistic practice.

Paternalistic practices can be justified, given that they carry the attributes of the following principles: (a) the harm principle, (b) the welfare principle, (c) the principle of moral legalism and (d) the appeal to uncertainty (Lim, 2002).

The Harm Principle

By virtue of the harm principle, an individual (for e.g. a doctor) or governing body can initiate an involuntary decision if it serves to mitigate harm to the individual or public at large although there is breach of individual rights of liberty and autonomy. For instance, making it compulsory to wear helmets is an act of paternalism in public health although it means infringement of individual rights; it seeks to provide safe driving experience to individuals. Helmet laws are seen to promote public health; however, there have several repeals of helmet laws on the argument of individual autonomy. On grounds of justifying mitigating of potential harm to public, harm principle of helmet laws is emphasized.

Welfare Principle

Strong paternalism on the other hand, although is difficult to justify due to the clearly voluntary act that it will be in conflict with, the best defence that could be raised is through the welfare principle. The do not drink and drive law is an example of the welfare principle as it seeks for the welfare of public at large rather than the concerned individuals. Although drinking is an individual’s choice, it cannot stake others’ welfare in the given justification that increased levels of alcohol consumption impact an individual’s decision making, cognitive ability and here the inability to drive safely. Hence, concerning the welfare others, drinking and driving is not legally allowed in most nations (Fitzpatrick, 2008).

Principle of moral legalism

The virtue by which an individual or an entity abides by the law of the state is known as moral legalism (Bennett, 2010). Within moral legalism, the acts done by individuals or groups are in obligation to the law of the state, i.e. they are morally legal within the state or a community or the group to which the individual belongs to. Hence, an action is either morally forbidden or otherwise upon assessing its adherence to the ethical considerations of the community or government. The principle of moral legalism is fallacious due to the fact that the laws of the state/group/community do not curtail every action that is not acceptable accordingly to not permit it, which signifies that there is space for every individual to value one’s personal freedom. On moral grounds, an action may be unethical; however, such action cannot be forbidden in which case there won’t be space for personal freedom and the notion of a free society. The government cannot always intervene in order to bring to justice every act that is morally wrong even at the personal level; hence, certain trespassing of ethics seems acceptable within certain groups (Bennett, 2010). Hence, the legal systems allow for certain reservations as every immoral act cannot be legally debated, therefore, considering that the actions have mild moral implications, the above said reservations are allowed.

Appeal to uncertainty

The above discussed scenarios indicate that there arises an uncertainty due to the dilemma of not being able to decide on paternalism, especially in the medical professionals. In order to appeal to such uncertainty certain sanctions are given from time to time. Given the assessed positive consequences to the decisions taken by doctors, soft paternalism is justified in order to remove the ambiguity of not being able to take decisions. In the condition of sickness, the patient is perceived as not being able to take proper decisions, hence, the doctor or a governmental body has the discretion here to aid in decision making through paternalism. Hence, when there is lack of public awareness give their inability to take decisions, the government may intervene giving rise to ethical contradiction which considering the end-results can be exempted. Hence, arising to remove the ambiguity associated with the uncertainty, paternity can be ethically considered. Hence, the argument of individual autonomy can be down-played at times although it might indicate breaching of individual rights.

Paternalism in health promotion

Within health promotion and particularly ethics concerning public health, paternalistic interventions by governing bodies have been justified only with the contention that the measures put in place are aimed at preventing the public from unhealthy conditions (Fitzpatrick, 2008). However, the efforts taken seem to endorse more than the requisite paternalistic practices often overriding autonomy and liberty of individuals (Seedhouse, 2009). The above author recommended that on grounds of empiricism and ethical considerations, individuals should be given sufficient autonomy within public only to be encouraged to promote health of their communities and not by paternalistic means. The existing principles of justice will have to be clarified before making efforts to encourage autonomy of individuals. Arguably, health promotion is concerned with the egalitarian principle of “social justice”; hence, it is the responsibility of healthcare professionals to articulate of public understanding of what justice is and how autonomy can secure it.

In recent times public health measures were seen to exploit autonomy through paternalistic practices although the aim of health promotion is the protection and promotion of public health (Williams, 1986). However, autonomy is not to be compromised with as individuals need equal autonomy on public health and their own health. Thus, the author of this paper believes that there should be respect for individual autonomy while also policing for public health. Autonomy of individuals should be promoted by public health measures. Nevertheless, as health promotion is aimed at providing social justice, it can be argued that certain measures can be justified; however those measures cannot be justified with the tag of “justified paternalism”. Considering the relevance of health promotion, unjustified paternalism is arguably challenging and conflicting to individual autonomy (Williams, 1986).

In general, medical professionals regard sharing critical information of patient might lead to depression and anxiety. However, considering the greater arguments of ethical concerns in today’s medicine, patient autonomy overrides paternalistic notions indicating that information sharing is essential. Here, (Seedhouse, 2009) emphasized that if there is no information sharing, it is likely to have detrimental impact on the patient or the public. For instance, the public should be fully aware of or informed of issues in respect of public health concerns such as the sharing of information related to harmful chemicals which are likely to incur huge social costs. Withholding information such as the above would not lead to good of public, thus shunning the paternalistic notion of working for the best interests of public (Hope et al., 2008). Thus, some of the consequences of not sharing information include epistemic impact, negative impact on privacy, and other psychological impacts on public. The above identified uncertainties can lead to potential risks. Hence, with exemption to justified paternalism in respect of health promotion, information sharing is important and helps in promoting autonomy.

Instances of paternalism in public health

Within public health there are many instances where paternalism occurs without it being noticed. For instance, restrictions laid down by governmental bodies to curb drug usage are paternalistic, aimed at the preventing dangerous impact of drug usage on health at the individual level (Bennett, 2010). As for instance, various governments made it compulsory for citizens to wear helmets while driving. In the above case, wearing of helmet has been made a compulsory choice even for those who do not wish to wear it as against their liberty. Of course paternalism in the above case intends to protect citizens from road accidents, which is an argument in support of paternalism (Williams, 1986). The most common paternalistic practice in medicine is to conceal information related to a fatal disease possessing a person only with the intention to make him/her mentally happy till they face the inevitable. However, (Jackson, 2006) argued that on ethical grounds healthcare professionals need to articulate with more to what extent they can practice paternalism considering the rationale of decisions made by a patient. Giving further instances, (Jackson, 2006) also observed that ban of sale of harmful drugs; restrictions on swimming in beaches where there are no lifeguards, etc. are other prominent examples of paternalistic practices concerning public health and welfare of people. Further, (Lowenstein et al., 2007) gave another instance where minor children are compelled to blood transfusions irrespective of their religion, although blood transfusions are unethical in respect of some religions.

Do not drink and drive law

As we see in most the countries, there are laws to prevent drinkers to not to consume alcohol while driving. Considering that drinking is a choice made at the individual level, anti-drinking laws are paternalistic in nature as they impose people to follow their insistence. Hence, anti-drinking laws violate personal autonomy. However, drinking and driving cause accidents that cause damage not only to the person’s health but pose harm to the public at large. While some nations completely ban drinking and driving, some insist that there should nil concentration of alcohol in a person’s body while driving (Melia, 2004). On the contrary, the governments should try and educate people not to drink and drive rather than imposing bans. Hence, the autonomy of the individual is promoted while serving the purpose of imposed bans.

Ethical priorities with respect to health promotion

Over the recent years, the attention towards ethics in promotion of public health has been growing with sufficient time invested for resolving the concerned issues and ethical dilemmas both by healthcare professionals and academicians (Jackson, 2009). Furthermore, paternalistic healthcare practices with regard to public health have been justified with the logical reasoning that the invading of autonomy is for prevention of unhealthy conditions of livelihood (Seedhouse, 2009). However, (Buchanan, 2008) noted that the efforts done for promotion of public health are mostly misplaced. The above author suggested that empirically and ethically it would be appropriate to encourage individual autonomy towards promoting public health instead of paternalistic practices. In this respect, (Buchanan, 2008) opined that the argument of paternalism within public health should be diverted towards articulation over principles of justice and how it can contribute towards better health awareness. In respect of health promotion, ‘social justice’, is posed as the justified stance for validating paternalistic practices, however, (Buchanan, 2008) argued that there issues of how the public perceives justice and this gap needs to be addressed.

Before, moving into the mainstream discussion on ethical priorities with respect to paternalistic practices within health promotion, it is important underline the difference between medicine and public health which is what health promotion is about. While medical practice is about health of individuals, health promotion is concerned about health promotion of the public at large (Buchanan, 2008). Thus, the ethical practices in public health differ from clinical practices which focus on treatment of individual patients. Moreover, health promotion is endowed with the social responsibility of promoting the health of the whole population and maintaining proper health conditions in environment (Seedhouse, 2009). Therefore, the distinction healthcare practices between clinical health and health promotion also accounts for different implication of paternalistic interventions in both cases. Also, the same distinction often makes it difficult for healthcare practitioners to justify paternalistic interventions in public health. The above ambiguity might lead to justification of paternalism within health promotion being misguided (Seedhouse, 2009). Due to the lack of focus, and on being misguided on paternalistic practices, public health practitioners are being are not able to articulate on the causes of morbidity and mortality and on how the awareness can be created without having to do with invading autonomy of the public. In respect of this ambiguity and ethical dilemma, (Beauchamp, 2006) believed that health promotion can be delivered better by promoting individual autonomy of people by motivating them for better and healthy behaviours rather than imposing on them. Such promotion of autonomy would also supplement the notion of ‘justice’ which health promotion is entitled to provide. In order to implement justified practices, it is important to understand public’s perception of justice which is also critical to address the ambiguity of ethical practices in health promotion (Bennett, 2010).

Currently, there is major focus on justifying the paternalistic interventions to promote health and to control unhealthy practices which according to (Seedhouse, 2009), deviates public health practitioners from adopting proper strategies that actually mitigate unhealthy behaviours. For instance, there are debates about whether the bans on certain advertising campaigns are effaceable without identifying the paternalistic concerns internal to those debates (Bennett, 2010). The above author underlined that paternalistic interventions, however mild they might be, only reduce the trust on healthcare authorities in the public. Hence, it is recommended that health promotion should seek to promote a just society that is commonly understood by the public.

In the view of (Campbell et al., 2005), the central concern within public health ethics is that with the aid of solid reasoning for promoting public health it overrides the autonomy of individuals. Emphasizing on the above, (Campbell et al., 2005) questioned that it is not appropriate for a government to make paternalistic interventions even though if it were to promote public health. In fact, it is a philosophical issue if the government were to intervene into human behaviour for it to promote health in the first place. Furthermore, (Dworkin, 2010) opined that paternalistic practices interfere with a person’s autonomy and decision making even if that person is actually capable of taking decisions with the only argument that it seeks to aid in the person’s welfare. The above observation throws light on the fact that autonomy is not to be intervened with especially when it is clear that a person is fully capable of decision making. Hence, autonomy as against paternalism empowers the stature of an individual. Moreover, (Duncan, 2010) opined that paternalistic practices prevent people from implementing their decisions which they have already made and thus showing that ethically arguable intervention.

Within paternalistic practices, there is a moral conflict which arises due to the assumption that the practitioner is right in taking the decision and therefore overrides other people’s decisions considering them as morally unequal even though if it were for the welfare of the person concerned (Bayer & Fairchild, 2004). From the above observation, it is clear that paternalism does not allow a person to choose to act in the concerned situation which in the case of health promotion seeks to fulfill its goals of promoting health. To address the ethical dilemma associated with paternalism, (Bayer & Fairchild, 2004) questioned the limits of paternalistic practice in public health; “what are the limits of the state in a liberal society in regulating, restricting or prohibiting behaviours that lead to premature morbidity and mortality, both in shaping, moulding or influencing the preferences and desires of its citizens?” Furthermore, (Beauehamp & Childress, 2001) identified five conditions which discuss the limitation or the extent to which paternalism can go ahead with health promotion, the five conditions are: 1) necessity 2) effectiveness 3) proportionality 4) minimal infringement as well as 5) public justification of health policies. The author stated that the above attributes of health promotion practice can ethically warrant its implementation concerns.

Limitations of paternalism

In spite of the fact that health promotion seeks to justify paternalistic practices on grounds of providing protection of public, (Beauehamp & Childress, 2001) argued that in terms of ethical considerations there is a lot of difference between control of disease causing agents and controlling their hosts (public), i.e. the author pointed out to ‘epidemiological transitions’ which reflect the above stated difference. Moreover, (Bayer & Fairchild, 2004) pointed out that along with economic development there has been a change in how morbidity and mortality causes have been observed with the domain of public health. Hence, such a change or shift has caused significant change in the evolution of public health practices and the ethics associated with them.

Within the works of (Beauehamp & Childress, 2001), it was observed that the causes behind deaths of people are not due to heart-attacks and cancers, but the real causes are life-styles and unhealthy habits such as smoking, lack of exercise, consumption food rich in fats, excess alcohol consumption, etc. The above instances causing morbidity provide sound scope for justifying the paternalistic practices of health promotional by ethically justifying its stance as striving health of the public. Thus, public health promoters and agencies tried to bring in interventions with the view of mitigating morbidity and mortality rates. According to (Jackson, 2006), some of the popular interventions made by public health professionals are: excise taxes, bans over advertisement of unhealthy goods, compulsory seat belts, helmet laws, the blue laws, prohibitions of drugs such as marijuana and other drug testing. In addition, the above author also reported that some healthcare professionals practice the habit of prioritizing to treat patients who have no deliberate complaints with regard to their habits for obtaining illness over those who have illness due to their own unhealthy behaviour. Apart from that (Jackson, 2009) opined that there are certain discrimination being made by employers towards people with unhealthy habits, such as smoking and policies that support those practices.

Considering the viewpoint of healthcare professionals that in order to control spread or development of infectious disease, justification of paternalistic practice is justified, however, thrashing personal libertarian values of a personal is neither good speaking of ethical considerations (Beauehamp & Childress, 2001). This is not clear to me Speaking of justifying paternalistic interventions, (Dworkin, 2010) opined that paternalism can be justified in terms of three arguments, utilitarianism, informed consents as well as weak paternalism.

In respect of informed consent, the above author observed that healthcare professionals argue that their decisions can be defended as the patients involved provide their consents for decisions with regard to their treatment, for instance, giving consent for a counselling session on smoking. In the above case there is not ethical concern as individuals place their trust on the therapists. However, obtaining consent from a larger audience is not feasible and thus the above might be problematic in health promotion (Cribb, 2005).

The other aspect, public health professionals consider as a part of their justification of paternalism is ‘weak paternalism’ which allows them to intervene considering that the person concerned is not in a position to take decision (Cribb, 2005). However, health promotion does not limit an individual and hence the public justification at large is important. In respect of behavioural interventions, public health professionals argue that unhealthy behaviour is associated with irrational behavioural attributes arising from oppression, peer pressure, family disturbances, etc and thus weak paternalism has ethical space (Buchanan, 2008). However, (Bayer & Fairchild, 2004) argued that the above stance is questionable as it is an assumption to consider unhealthy behaviours as irrational which needs more psychological evidence from behavioural economics. Hence, weak paternalism cannot be fully justified.

Utilitarianism is another argument of public health promotion under the belied that what is the reasonable to most extent on the basis of morality and ethical consideration believed to give the best for more number of people can be considered ethically justified (Dworkin, 2010). Within utilitarianism, the end-results are used to justify the actions (paternalistic decisions) which are debatable on ethical grounds (Dworkin, 2010). As for instance, how does ban on smoking truly save money for any government? Hence, it utilitarian justification cannot fulfil the need to justify paternalistic practices within health promotion.

Notwithstanding whether the above arguments validate or do not validate the ethical justification for paternalistic practices in public health, the author of this paper is of the belief that restriction of autonomy is not a healthy choice in accordance with ethical and empirical concerns. This paper is of the belief that restriction of autonomy only misguides the ethical justification of paternalistic practices. In the work of (Doxiadis, 1987), it was emphasized that empirically speaking there are always possibilities for people enjoying better discretion and autonomy to live better lives in terms of health. On the contrary it is always possible for individuals with restricted autonomy to live a life poor health on the account of work stress and other repressive situations (Doxiadis, 1987). Hence, it is suggested that the health promotion authorities should strive towards promoting autonomy and not restricting it and that can also help towards achieving what health promotion is entitled to achieve.

Considering ethical concerns, paternalism is viewed as a pre-conditional restrain that can limit autonomy which on philosophical grounds contributes to well-being in people (Campbell et al., 2007). The above author believed that autonomy is very much linked to the principle justice as it promotes liberty and self-determinism in humans and autonomy also creates social equality. Hence, giving importance to one form of justice (social justice) should not restrain the other (autonomy being another form of justice). Furthermore, (Kass, 2001) opined that it is important not to consider liberty as a synonym for autonomy as these both are different in a minor sense. While liberty is freedom that sanctions a person to do whatever he/she wants irrespective of whether the action stays in its limitations of harming others. However, (Kass, 2001) also observed that autonomy is a combination of free will, i.e. to do things with freedom combined with responsibility. Giving consent is also a part of autonomy, further, (Melia, 2004) considered autonomy as the positive freedom that promotes self-respect.

Conclusions

As we have seen, the elaborate discussions presented in this paper dealt with both the sides of the major debate “paternalism” both from the medical point of view as well as from the ethical substance involved. Within health promotion and especially with regard to public health, the author recommends information sharing with public as to mitigate paternalistic practices. However, given that health promotion is aimed at social justice of the public, “justified paternalism” is a notion difficult to argue with the help of arguments supporting individual autonomy. Hence, paternalism in public health has to be minimized as there is huge emphasis on civil and libertarian laws which endorse autonomy as having more weight than paternalism.

The author of this paper endorses upon the value of autonomy being of focal importance as it instils confidence and self-respect in individuals. Individuals should be in a position to decide for them and not to be enforced upon externally to make decisions until and unless they lack the cognitive ability of decision making. At large, in context of health promotion, public cannot be said to have no capability of taking decisions or being autonomous, hence, paternalism cannot be justified on the means of thwarting autonomy. Dworkin (2010) pointed out that autonomy does not simply mean liberty of taking decisions irrespective of consideration to circumstances, the author opined that autonomy also means that an individual consents others decisions when perceived as doing good to him/her. Hence, upon informed consents, paternalistic decisions taken by healthcare professionals can partially be justified as ethical means. Therefore, public justification for health promotional activities can be free from paternalistic concerns. More efforts need to be made by health promotion authorities to promote not only social justice but autonomy which also forms an integral part of the justice. Thus, this paper endorses that promoting autonomy can also serve as a means of educating people and driving them towards healthy living habits.

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