Paternalism up a Mountain

“Paternalism” is one of those words that has a hell of a lot of power.  On several occasions, I’ve seen it used as a trump to shut down an argument: saying “But that’s paternalism” is, at least sometimes, treated as a way of showing that anyone arguing in favour of the allegedly paternalistic action is an imbecile, and has therefore lost the argument by default.  I suspect that this is due to a bastardisation of the (already iffy) “Georgetown Mantra”; but it does seem to be a position horribly common in medical schools.  It’s also very unsophisticated.  Whether or not something is paternalistic seems to me to be less important than whether it’s justified.  Something might be unjustified, and the reason for that might be because it’s paternalistic; but it doesn’t follow from that that no paternalism could be justified.  In just the same way, too much bleach or bleach in the wrong place is something you’d want to avoid; but it doesn’t follow that you should avoid bleach at all times and at all costs.

I want here to tell you a story based on something that happened just over a week ago.  My Dad and I had – oh, don’t ask us why – signed up to climb Kilimanjaro.  We were following the Machame route, which slowly circles around the mountain for four days, before a final push at midnight on the fifth in time for sunrise at the top.  Most of the campsites are just a shade under 4000m above sea level; this gives you some time to acclimatise.  However, on the third day, you do have to go up and over a pass that’s around 4600m, before descending to about 4000m to camp at a place called Barranco.  Neither Dad nor I was taking Diamox, which is the main drug used to combat the effects of altitude.  (I’m suspicious of it: I worry that it might mask the early signs of altitude problems, and so leave you more vulnerable to something more acute.  After all, if you get a headache, you’ll slow down naturally, won’t you?  Remove the headache, and you might keep on doing too much until you get much iller.).  On the third day we both got thumped by altitude sickness.  That night, having somehow mustered the energy to unroll our sleeping bags, but unable even to eat, we both decided that we’d had enough.  We were going back down.

I was disappointed – but I’d failed to get to the top of Kili almost exactly 15 years ago, in August 1999, having reached 4800m before giving up; and I’d failed to get to the top of Tungurahua four years before that on an interesting-ways-to-kill-the-sixth-form school expedition, having given up at approximately the same altitude.  Maybe 5000m or so is just my genetic limit; apart from me and Dad, everyone else in the group seemed to be fine.  It could be that I’m not made for mountaintops, just as I’m not made for living underwater.

D&L
Living and Dad

So, at dawn on the fourth day, we told our guide, Living, that we were out.  He gave us Diamox, and an anti-emetic, and told us that we had two options to get off the hill.  From Barranco, we could either turn back and go the way we’d come the day before, and then join a descent route from the previous campsite; or we could do today’s climb up and over Great Barranco, and descend from the next camp.  The climb would not be insignificant, but it wouldn’t take us as high as yesterday’s, and it was only a few hours walk between camps.  Obviously, we chose the latter as the less bad option.

Having topped up Living’s advice with ibuprofen and as much tea and toast as we could handle, we walked; and as we walked, we began to feel better.  By mid-morning, we were pretty much back on form.

Now, Living really knew his stuff.  He’d been checking up on us since that third evening, and it was plain to me from that evening that he wouldn’t let us continue the climb if he didn’t think we were capable of completing it.  But I also wondered if the converse might also be true: that he wouldn’t let us turn back if he thought that we could handle the ascent to the summit.

One of those father-and-son moments. And yes: my Dad was wearing a kilt.

The upshot is that we both got to the top of the hill less than 48 hours later.  It was ridiculously hard work, but we made it.  In fact, Dad was the first person from our group to make it to the top, reaching Uhuru Peak at about 6:45 on the morning of the fifth of August.  It’s amazing how you can go from feeling wretched to feeling surprisingly good in the few minutes it takes the sun to rise.

So we got back to Moshi after seven days on the hill, and met up with Living and the other guides that evening, where Living admitted something that I had suspected to have been the case anyway: that of course there’s an escape route down from Barranco camp.  That stuff about choosing to turn back or go on had been false.  As I suspected, he wasn’t going to let us turn back, given his belief that we could reach the summit (he, and all the guides, had been keeping an eye on every walker and assessing us at every point on the walk anyway), and that in some sense we really did want to.  After all, we’d spent a lot of money to get there, so a desire to see the top does seem like a reasonable thing to infer.

What Living did was, undoubtedly, paternalistic.  He acted according with what he thought were our fundamental desires, rather than on what we said we desired (and actually did desire) at a given time.  More: he told a lie in order to get us to achieve what he judged – accurately – that we really wanted.

Were that a clinical situation, many people would be having the vapours if they came across behaviour like that.  The GMC would be running around the room screaming, and the MDU would tell the clinician that he was, really, on his own from now on.

And yet…

I find it hard to accept that either Dad or I was wronged by Living.  (Certainly neither of us was harmed by him.)  Admittedly, the fact that a person doesn’t think he’s been wronged isn’t a sign that he hasn’t been – wrongs have to do with the actor, not the acted-upon.  But, still: I can’t persuade myself that Living’s paternalism was unjustified.  In fact, I think it was wholly justified.  I’m glad he did it.  If I’m right that it was justified, here’s an instance of paternalism that is not only not-wrong, but that might even have been morally required in some sense.

Why does this matter?  Simply because I think it helps break the back of the idea that merely pointing out that something is paternalist is enough to tell us that we shouldn’t do it.  Of course, that’s pretty obvious when you think about it; but it is worth thinking about.  I’ve got a sense that it’s not thought about nearly as often as it should be.  It might still remain the case that paternalistic actions are never justified as a matter of fact, or that Living’s might be the only justified paternalism that there has ever been.  That doesn’t matter when it comes to assessing the principle, though.  What matters is that it indicates that paternalism has to be taken on its merits, and in context.  Simply to make “Yah!  Boo!  Paternalism!” noises simply won’t do.  I’ve got the aching thighs and chapped lips to prove it.

Oh: and I’ve been persuaded of the virtues of Diamox.  As if I’m ever going to climb another bloody mountain ever again.

  • Craig Jonathan

    Great post Iain. But if one adopted the Gerald Dworkin/Harry Frankfurt definition of autonomy then Living’s actions would not have been paternalistic. By overriding your first-order desire to go down the hill in order to fulfil your second-order desire to reach the top, he would have been respecting your autonomy according to this theory. It all depends on how you are defining autonomy.

    However, I’m not really persuaded by the Dworkin/Frankfurt theory and do think an individual’s autonomy can sometimes be overridden on utilitarian grounds so ultimately I agree with you on this.

    • Ta!
      I’d fight shy of the utilitarian arguments, myself (but then, you knew that…): for me, if anything, it’s more of an Aristotelian thing. I’m less bothered about whether the decision was optimific – how could you tell in advance – as by whether it is permissible, justifiable, or even admirable on its own terms. I kinda think that it could be – which means that at least some paternalism could be; and the outcome doesn’t seem to be all that important in reaching that position.

  • Divine Banyubala

    Great feat Iain. Congrats!!!
    As a clinician, I have always argued that recognising that a particular clinical situation raises questions of paternalism is the key thing…then justifying why it may or may not be right in a particular clinical scenario (judged on a case by case basis). So the mere fact that a practitioner has acted paternalistically does not mean he/she may have acted unethically or done something terribly wrong. After all, doctors are not and ought not be, disinterested in the clinical situation of their patients. Clearly I agree with utilitarian justification of paternalistic actions under certain circumstances…….but the onus is on the person seeking to act paternalistically to provide the reasonable justification of their action.

  • DietrichB

    I definitely don’t agree that LYING done by a doctor to justify anything is ever a good idea regardless of what name you give it. Your example is quite far fetched when compared to today’s typical medical relationships with most having very dubious benefits. For example, the statin debacle whereby these useless, dangerous drugs have been pushed by Big Pharma’s lucrative profits while hiding the usual dangers is an excellent example. Whether doctors know the truth about these drugs and that the ever expanding guidelines are created by those with huge conflicts of interest, they should not be inflicting them on their so called patients based on lies or paternalism which you seem to see as equivalent since they do more harm than good. The same is true of a majority of drugs and treatments today driven more by profits than health. And whether a doctor is duped or complicit, his/her lying to patients is a huge betrayal of the right to informed consent!
    I don’t think your example is at all comparable to the doctor’s office, but even in your case, the so called paternalistic lie could have done much harm if either you or your father had a health or other problem that could have made the lie much more dangerous.
    And we all have to grow up at some point and give up beliefs in Santa, the Easter bunny and the Tooth Fairy. Adults have a right to informed consent since no doctor is omniscient and can know everything about today’s many bogus treatments, everything about the patient or be up on all research that the patient will be more motivated to investigate since it affects his/her life.
    All evidence points to the reality that it is best to avoid main stream doctors today.

    • There’s quite a lot going on there – not all of which has much to do with the post.

      I’m puzzled about your comment, though. My claim was simply that it’s unhelpful to talk in terms of paternalism being always wrong, because there could be times when it isn’t. Even if there are risks, those risks may be worth taking. The situation up the mountain was a situation in which that strikes me as having been the case. There’s no reason why there couldn’t be situations in the clinic where it is, too.

      Your response seems to be simply to assert that paternalism is always wrong. Isn’t that a bit of an ignoratio elenchi?

      • DietrichB

        You are the one who made the analogy between your hike and medicine.
        Yes, as a woman I do believe paternalism and patriarchy are always very wrong and deadly if you look at all of the evils that have resulted from them from Adam and Eve to the present.
        And no, I don’t take the myth of Adam and Eve literally though the great paternalistic patriarchs did to project their own evil on women from Day 1.
        Getting back to the medical system, it is so corrupt I mostly avoid it like the plague and do my own research unless I have a dire, life threatening emergency due to all the fraud, conflicts of interest and other perils of modern medicine. There is enough lying already without adding any more for sure like too many doctors selling Big Pharma infomercials while on their dole. Bogus studies, ghost written journal articles, fraudulent claims about drug benefits, hiding/covering up deadly drug effects, etc.!
        For example, see books like Deadly Medicines and Organized Crime, Pharmageddon, The Truth About the Drug Companies, Selling Sickness, Overdiagnosed, Bad Medicine and tons of others.
        And the mental death profession that sold out to Big Pharma in the 1980’s to create their voted in bogus disorders like the latest bipolar fad fraud in their junk science DSM bible to push the latest lethal drugs on patent is a real piece of work well described by Robert Whitaker in Mad in America and Anatomy of an Epidemic, and Dr. David Healy’s Mania: A Short History of Bipolar Disorder among tons of others. The fact that the rest of the medical profession sold out to this monstrosity for greed and profit is unbelievable. See how the infamous Dr. Joseph Biederman single handedly created the bogus, deadly child ADHD and bipolar epidemics to push deadly kiddie cocaine and neuroleptic drugs on children and toddlers no less to make millions under the table with his real employers Johnson & Johnson while promising positive drug studies in advance. He made the headlines in the Boston Globe and New York Times as did Rebecca Riley who died at 4 years old on his ADHD/bipolar drug regimen! He is quoted as comparing himself to God.
        And though you may rebuke me for supposedly unfairly painting all of medicine with the same brush, the fact that these predatory murderers among you are allowed to thrive with a code of silence so they can destroy countless lives makes the entire profession complicit and guilty for burying their hands in the sand. Dr. Fred Baughman, Neurologist, and author of ADHD FRAUD, exposes modern psychiatry with its bogus, voted in stigmas like ADHD and bipolar 100% fraud and the worst medical crimes against humanity ever. But, now regular GP’s are doling out these bogus stigmas and deadly drugs!
        So, see I do my own homework now since I’ve learned through very painful experience that the medical/mental death system is just another old boy network industrial complex that mainly benefits the wealthy in power and preys on the rest of us to sell sickness and toxic drugs for life while medicalizing all of life.
        Finally, your topic was about paternalism and you used the hiking story as an example. From my research and experience all paternalism is vile, self serving, narcissistic and dangerous. I could give many great examples but I will spare you.

        • It’s not really an analogy. I didn’t claim that the climb was like medicine; I claimed that here was an instance of paternalism that was – at worst – not as bad as all that.

          Your claim about your research appears to repeat the ignoratio elenchi, though: given an example of apparently not-all-that-bad paternalism, it doesn’t seem like enough simply to reassert that all paternalism is bad in principle. (Note that no number of examples will establish the principle, but one decent counterexample will, all else being equal, wreck it.)

          I’ve got no idea what your sex, or the stuff about Big Pharma, has to do with the matter, either way. Ho hum.

  • I’m all in favour of analogies, and I take this to be analogous to health promotion, rather than consent. You weren’t being asked to acquiesce to something being done to you, but being given inadequate and misleading information to nudge you both along. Just like health promotion. Maybe Living had an interest in your success, or (just) that he thought he knew better than you where your interests lie, or that he didn’t judge you capable of making the calculation. Which, I wonder, would he use in defence? I also knew that you’d fight shy of utilitarianism, but aren’t these calculations, in public health, usually made in order to calculate rules of action? Stories about individuals and their acts challenge rules based reasoning, and it seems to me that the power of your story lies in the fact that things did work out well for you, and therefore (retrospectively) the lie looks justified in terms of its consequences. How about this as gruesome counter-factual headline: ‘University lecturer and his father fell to their deaths after being misled by tour guide.’ Has he wronged you now?

    My points? (1) I happen to agree that paternalism isn’t always bad but detailed justification is required but is seldom given. (2) We’re all consequentialists of one sort or another even if we say we aren’t. (3) Stories and analogies are endlessly fascinating (4) Congratulations for climbing Kilimanjaro – that’s impressive despite
    the nudge (5) Both of you in kilts would have made a better picture.

    • We’re all consequentialists? *narrows eyes*…

      Possibly Living did have an interest, if only professional pride, in our getting to the top; but I think he was also far better informed about both of us than we were; he and the other guides had, for three days, been watching everyone in the party, assessing how they walked and so on, to get a picture of what they could do, and what would be the best strategy on the hill.

      I’m not sure that the justification is best made in terms of consequences, though. After all, a decision can be epistemically justified even though it’s wrong. (Newton on gravity would provide a nice example: he was wrong, but it’d be unreasonable to expect anything better; it was a decent account given what was possible at the time.) On that basis, the assessment of whether a walker is capable of completing the task may turn out to have been wrong, but could still be epistemologically to-all-intents-and-purposes sound and beyond reproach. Any moral judgement about the decision would be tacked on to that – although it’d also take into account other things. Either way, if you want to ascribe a badge to it, I wouldn’t go for consequences. It seems much more to be a question of what’s reasonable, and that invites – if anything – more of a virtue-based analysis. (OK: that’s not perfect; but you get the picture.)

      I did consider wearing a kilt, by the way, but opted to take a kite instead – which I forgot to take on the final ascent. There was no wind up there anyway.

  • Sarah Smith

    Great post! I’m not really against paternalism myself. However, it does strike me that had something gone wrong; you developed side effects to Diamox, your father tripped and broke his ankle, and so on, and then you discovered the deception, you might have responded differently. Yes, your guide’s expertise meant that the chances of something bad happening were much less than you thought they were when you wanted to go down. But still, he could not eliminate every risk. And not only do even small risks occasionally eventuate but some guides overestimate their own expertise. If you had tripped over and been seriously injured on the additional climb, do you think you would have had the same response?

    I actually think the main function of anti-paternalism is to protect guides/ doctors- and I think it is reasonable of them to want this protection

    • It’s possible that our response would have been different if something had gone wrong – but it’s not a given. More importantly, though, it’s not obvious to me that that’d make any difference to the actual (alleged) wrongness of the paternalism. As I said in the OP, any wrongness would have to do with the actor, not the acted-upon; if it’s wrong, it’s wrong irrespective of whether Dad and I were inclined to think it wrong. And I’m not convinced that it was.

      The contingencies you mention are, of course, contingencies and nothing more. We could equally well imagine something going wrong on the way down – a broken ankle, a sting from a nasty insect, or whatever; that wouldn’t make any difference to the moral merit of the decision either. You have to make judgements about what’s reasonable based on imperfect information and an uncertain world at the best of times; my suggestion is that it’s the reasonableness of the decision at the time that makes the most difference to rightness and wrongness.

      It’s an interesting claim you make about anti-paternalism and protection. I’m not sure that that’d alter the moral arguments, but it might help explain why a particular kind of moral argument is so widely accepted within the profession…

      • Sarah Smith

        I think there is some form of moral argument in there for having the policy against paternalism.

        How far is a doctor/ guide required to go to ensure the best outcome for a patient or guidee?

        Whilst you might be right that the outcome is morally irrelevant, there will be many who do not see it this way (just read the daily mail once in a while). And of course it is impossible to finely balance such risks, and up a mountain he only has access to a certain amount of information. So if he takes this paternalist decision he effectively takes responsibility for these inevitable risks.

        What’s more he really has to do this without asking you- he can’t say. “Let me see, do you want to know the real way down or the way down that I think will persuade you to carry on?”

        On the other hand, almost the same could be achieved by giving you the full information and the reasons why he thinks going on is the best course. And the only person who will be affected by your decision is you. Maybe in the grip of your illness you would not see it so clearly as he does and because of this would make the “wrong” decision. However, I don’t think that overrides his need for protection from taking on responsibility for risks that only affect the patient/ guidee.

        I don’t think that a guide or doctor has a duty to risk the consequences if others less philosophical than yourself get annoyed that they are the 1 in a million person who is severely allergic to diamox or whatever.

        There might be exceptions for those that don’t have competence and if the decision affected third parties, then we might require a guide or doctor to take responsibility on their behalf. But I think patients / guidees have some duties towards their doctor in the sharing of responsibility.

        They are responsible for telling you what they know and what they don’t know, what they recommend and why. But you are responsible for deciding for yourself what to do and taking the consequences.

        • Well, I guess that “the best outcome” is a phrase that will admit of several interpretations. It’s possible that one defensible version could even include significant physical harm, if the (less tangible) good of success is rated highly enough. There’re plenty of stories of people doing extraordinary things despite injury.

          Whether others see the outcome as relevant is, of course, neither here nor there; that’s of anthropological, not moral, interest.

          When it comes to risking adverse consequences, I’m not sure I’m with you; I’m not sure that anyone could avoid taking that risk, given that any course of action could potentially go wrong! Correspondingly, when it comes to the responsibility point, I guess that that’s something that neither Dad nor I could eschew: had we dug our heels in, that would’ve been that, and we’d’ve gone back to Moshi early.

          What matters is whether Living’s action was defensible. You’ve made an assertion that suggests that professionals shouldn’t be making a decision on others’ behalf, or skewing the information. But that’s exactly what I’m scrutinising here. If I’m right, your assertion would seem to be false at least some of the time. Even if it isn’t, don’t you need more of an argument to back it up?

        • Sarah Smith

          Sorry I don’t mean that his action was wrong. I mean that it is or would be wrong to expect guides/ doctors to do this and that a policy of not doing so is better morally. Because it tilts the balance of responsibility too far towards the guide / dr and away from the responsible person.

          Yes you still had the ultimate decision . ButYou are less responsible if some info is withheld from you surely. That’s why people used to be able to sue cigarette companies ( the opposite of paternalism I guess) because they weren’t responsible since they didn’t know the risks and indeed they had been kept from them. This is the inverse case but it meant that the company was responsible. I argue that paternalism makes the guide / dr responsible in a way that is unfair to the guide/dr

          I know it is off your argument and I don’t think your guide is a moral monster ! I just think the fact medicine / authority is a two person activity is overlooked.