- 10.00: Trial lecture: "Do doctors in public healthcare systems have an obligation at times to be coercively paternalistic?"
- 12.00: Public defence.
Opponents:
- First opponent: Professor Jonathan Ives, University of Bristol
- Second opponent: Senior lecturer Berit Bringedal, Institute for Studies of the Medical Profession
- Leader of the committee: Associate professor Andreas Eriksen, Centre for the Study of Professions, OsloMet.
Leader of the public defence is centre leader Beate Elvebakk, Centre for the Study of Professions, OsloMet.
Supervisors:
- Associate professor Marte Mangset, University of Oslo.
- Professor Bjørn Hofmann, Norwegian University of Science and Technology and University of Oslo.
Thesis summary
Doctors’ paternalism means overriding patients’ autonomy or preferences with the intention of benefitting them - for example, through coercive treatment, lying about diagnoses to keep their hopes up, or compelling them to consent to procedures.
Over the past century, paternalistic practices by doctors have increasingly been deemed unacceptable, and many have instead embraced shared decision-making - an approach where doctor and patient collaborate to reach a decision.
Research question
In this thesis, I focus on paternalism in doctor-patient communication - that is, cases where the doctor tries to make the patient consent to one course of action, but where the patient prefers another. I call this form of paternalism communicative paternalism.
My discussion rests partly on philosophical and normative analyses, and partly on qualitative analyses of video-recorded doctor-patient encounters from a Norwegian hospital.
The thesis seeks to pinpoint what, exactly, doctors’ paternalism is; where the line falls between non-paternalism and paternalism; and why doctors’ paternalism is problematic. However, I also discuss whether paternalism actually is as bad as its reputation suggests, and - if doctors are going to be paternalistic - how they should go about it.
In addition to discussions on these topics, I propose a model for combining empirical data with conceptual and normative analyses, drawing on the field of empirical bioethics. The thesis consists of three articles.
Articles
In the first article, “Paternalistic persuasion”, I argue that a doctor who persuades a patient to consent to a treatment is acting paternalistic, while convincing him is not paternalistic. Trying to convince a patient, as I define it, means aiming for the patient to want the treatment, while persuasion, on my definition, means making the patient consent to the treatment although he prefers not to.
The topic for the second article, “Scared decision-making”, is how patient fear may affect shared decision-making. I further discuss how doctors may respond when patients are reluctant about suggested treatment due to fear of what it entails. If they remain scared and reluctant about the treatment, any decision is not shared and the decision-making process might end in paternalism, I argue.
In the third article, “Four types of paternalism”, I categorize the paternalism I have observed into four communication styles - the fighter, the advocate, the sympathizer, and the fisher - and discuss them normatively.
Discussion
In my thesis, I also raise the question about whether paternalism, although it has its normative problems, is actually that bad after all - considering that many patients struggle to make good decisions for themselves? And doesn’t shared decision-making too have its normative pitfalls?
Rather than banning paternalism altogether, I therefore propose that we also discuss how it should be performed.
My preliminary answers to this question are highly tentative, but I do suggest that doctors should avoid hidden paternalism, such as manipulative nudges or double speak, and that they should act sympathetically, but that acting too sympathetically when being paternalistic might also - perhaps paradoxically - be problematic.
