Justifying paternalism toward clients?


Got a newsletter this week that had an article about paternalism with clients who suffer with eating disorders. The author begins with this statement:

Some clients are pressured into treatement by family, friends or physicians. Other clients enter treatment willingly because they want to make changes in their lives, but those changes may not include their eating behaviors. Still other clients profess a cincere desire to change their eating behaviors, but only if they can be assured that they will not gain a pound. Virtually all clients are ambivalent about giving up their eating disordered behaviors, and some outrightly refuse to change these self-destructive patterns.

All clinicians who work with eating disordered clients are faced with an ethical dilemma: how to attend to the well-being of clients who resist recovery from a potentially life-endagering disorder, while respecting the clients’ right to autonomy and self-determination.”

How does a counselor balance individual autonomy with protection of health and life? The author tries to distinguish between weak and strong paternalism. Weak, she says, legitimizes  interfering in with the ways a person achieves a desired goal. Strong paternalism believes that some goals are confused or mistaken and thereby require intervention.

The author does a fine job talking about the challenge of allowing clients freedom and yet strongly encouraging clients in a particular direction. Really, this raises the issue of how do we “sell” something that client yet do not know that they want? Unfortunately, little in the way of helpful answers are given.

The problem with paternalism (I know what is best for you) is that it naturally leads to coercion. Coercion, even with a smile, rarely results in positive change. Instead, we need to talk to clients about choices. We need to do so early and often. They do have choices. Sometimes many, sometimes few. However, they have them none-the-less. Our job is to help them see the consequences, the benefits, etc. Some choices made will have specific and immediate consequences. If I choose to steal a car, I may be jailed and have my rights limited for a period of time. So too with some self-harmful choices. If a client wants to kill themself, then I have the right and responsibility to stop them. This is not paternalism but momentary protectionism. I do not claim that hospitalization is what is best, but I do claim that it will extend the life of a suicidal client. By extending their life, I am providing an opportunity to return to their choices and reconsider God’s gracious hand on them rather than act impulsively to deep pain.  

3 Comments

Filed under eating disorders, ethics

3 responses to “Justifying paternalism toward clients?

  1. Karen

    My views about eating disordered thinking changed drastically after reading about the Minnesota Starvation Study conducted by Ancel Keyes. My conviction now is that the starved brain is unable to view its own body rationally until about a year after the body has reached healthy weight. Even then, there will be the tendency to still see oneself as “fat”. But with weight restoration, the mind then has the ability to counter the lies.

  2. Very thought-provoking. We can talk all day long about “choices” but in the end, if a self-destructive person keeps “choosing” self-destructive behaviors, protectionism will win. You can call it paternalism or coercion or whatever you want, and we can argue all day about a person’s right to choose their own destiny; but the bottom line is that we will either intervene or we won’t. We’ll either override the person’s own right to make their choices, or we won’t. I don’t think it’s ever an easy decision.

  3. Rachelle, welcome to the site and thanks for your comments. You are very right that these aren’t easy decisions. I think the question for counselors is how quickly they move to the “deciding for” action with clients. I find that those who feel they have options are less likely to choose impulsive, self-harmful ways out. But, you are right if the person persists in choosing self-destruction, we do move to protect them from themselves. This intervention for outpatient counselors is short. We decide to get them to a hospital for admission. Where much of the paternalism happens is at the hospital over the next few days to weeks.

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