Ethics and Professionalism

12. Paternalism and Client Autonomy

o 12 PATERNALISM AND CLIENT AUTONOMY The ideal of dedication to proficient service for all in need asks professionals to transcend self-interest. Under favorable conditions , which society should provide, their own interests will be served fairly in the course of serving others; but the needs of clients, employers and the public determine the way they do their work, not their own needs and certainly not their wants. The power they have been granted by society must be used to the benefit of all as far as they are able to ensure this, not to exploitation of some for the benefit of others and themselves. Professionals, however, must not only want to serve; they must know how. The very dedication to service, together with the proficiency that sets them apart from those whom they serve, may tempt them to cross another boundary into improper behavior . The attempt to serve can easily tum into illegitimate forms of paternalism. The term 'paternalism' has floated about in the discussions of moralists for about a century in search of a stable meaning as its users exploited one and then another analogy between the parent 's relation to children and other forms of human interaction. Inspired by Mill's On Liberty to propose categorical bans on some patently offensive patterns of behavior, the first authors employed a narrow definition, concentrating on coercion as a means of protecting the coerced from harm. As similarities were noted between the intentions behind this and other ways of promoting the welfare of persons without their consent, the concept of paternalism was broadened. In the process, it came to cover some patently desirable actions. We now realize that a categorical ban 275 PATERNALISM AND CLIENT AUTONOMY on paternalism is out of the question. Some of its forms are justified and even obligatory, and a fairly complex set of principles is required to distinguish between justified and unjustified forms. Indictments of Professional Paternalism Attention to professional paternalism has been fairly recent, since professionalism only lately has come to be a dominant force in social life. Once recognized, however, it has been subjected to broadside attacks. Wewill consider two examples and prepare the way for a more balanced view by noting their excesses. These are the assaults of Lieberman and Illich. The professions define human needs the areas under their jurisdiction and professionals subtly shape the goals of the individuals whom they serve. Professionals thereby take the lead corporately and individually in constructing social reality for the rest of society. Lieberman and Illich see this as a threat both to political democracy and individual autonomy. Lieberman charges that self-aggrandizement and paternalism lead professionals to systematically and deliberately mystify the character of their work. Professionals are dividing the world in spheres of influence and erecting large signs saying "experts at work here, do not proceed further." The public respects the signs and consequently misses the fact that what goes on behind them does not always bear much relation to the professed goals and activities of those who put them up. Professionals frequently say one thing and do another and assert that the layman's inability to find consistency between talk and action is caused by his inherent lack of insight into the professional mysteries. But the gap exists, and it has important political, economic , and social consequences; the public is losing its power to shape its destiny" Lieberman believes that the public acquiesces to this grab for power out of frustration at the complexities of modem life. A principal feature of our managerial, affluent, post-industrial, frenetic , and compulsive life is a willingness to delegate most facets of it to others. We are trained, but unschooled; lettered but unlearned, intelligent but undisciplined. Wehave turned over to others the power to make legal, medical, aesthetic, social, and even religious decisions for us.' 276 THE PROFESSIONAL IDEAL The professions have exploited the distraction of the public to usurp functions of government "without public debate and without the possibility of compromise or change." Lieberman comments mildly, "The management of public affairs by groups not representative of the public is not an ideal ardently sought by democratic or open-society political theorists or by common men, but it is a reality being achieved by professionals.r" Illich indicts modern society in similar terms. This century has relinquished individual decision to dominant and domineering professions, producing a total institutional control over the individual's life...