overrides or limits the exercise of their autonomy is called paternalism 6or
sometimes parentalism). As we have seen ,paternalism is a constant temptation in
health care ,and if we are to respect autonomy there should be a presumption
against it ,but are there occasions on which it might be justified?
There are two reasons why nurses may ,from time to time ,be justified in acting
paternalistically. First ,autonomy is partly a matter of degree. How autonomous a
choice is depends upon a number of factors including the level of understanding
and reasoning of the chooser. A choice made by a client may be judged autono-
mous at a minimum level ,and as worthy of respect and serious consideration. Yet
judged against a more demanding standard the same choice may not be seen as
sufficiently autonomous to decisively settle the matter. Second ,it is often difficult
to assess the degree of autonomy of a choice. Sometimes we cannot be clear what
lies behind a decision or action ,in particular how far it rests upon a misperception ,
awhim ,a disturbed temperament ,or external pressure. Under these conditions it
might be justified to postpone a decision ,or even override an apparently auton-
omous choice ,in order to assess how far a choice is really autonomous. Both of
these reasons are more likely to come into play if the risk to welfare is great 6a
suicide attempt is the paradigm case here).
Paternalism involves limiting a person's exercise of autonomy for his or her own
sake ,but there are ,of course ,other reasons to limit the extent of what an
individual wants. Respect for persons means taking into account the interests and
wishes of all those affected. Normally this means that the client concerned has the
overriding voice ,but this is subject to important qualifications. A patient or client ,
even if we assume they are `fully' autonomous ,cannot merely demand any inter-
vention whatever the cost to other people ,or regardless of the views of health
professionals. If we are to respect persons then nurses cannot merely be used as
objects or tools to meet other people's demands ± doctors or patients. This will
happen unless they are involved in appropriate decision making ,and allowed to
withdraw in a responsible fashion from involvement when they strongly object to
what is decided. Also there is sometimes more than one client. A nurse may ,for
example ,be supporting a bereaved family. Here respect for autonomy necessarily
entails balancing the wishes of different individuals together ,and having regard
for the well-being of the family as a whole. Finally a nurse acting as a budget holder
or policy maker has to consider the overall implications of decisions for the general
population.
2.3 Utilitarianism and the public interest
This takes us on to a second cluster of problems concerning the promotion of
welfare. How are nurses supposed to balance together the interests of different
individuals ,and how are they to consider both the needs of their immediate clients
and a commitment to the general welfare or the public interest? A large number of
practical dilemmas turn upon these two questions. Dramatic examples of the first
kind include those cases where individuals donate organs to others ,or cases in
which the interests of pregnant women and fetuses can come into conflict.
Dramatic examples of the second kind arise when clients are a potential danger to
TheEthicalDimension 23