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The Paternalism Problem

The central problem of policies that restrict access to pharmaceuticals to prescription is paternalism. The primary purpose of such policies is to protect consumers from bad decisions they might make about the use of drugs if they have unrestricted access. We first need to be clear on exactly what is meant by paternalism and why it is a problem.

The Definition of Paternalism

Paternalism describes an action or policy whereby one person acts for the purpose of benefitting another against that person’s substantially autonomous choice (Dworkin 1972, 1988; Gert and Culver 1979). From this definition, it is clear that only persons who have the capacity to make substantially autonomous choices about the issue at hand can be the subjects of paternalism. Paternalism is always an action that violates autonomy, and it is for that reason that it is morally suspect.

Hence, taken literally, one cannot act paternalistically toward small children or mentally incompetent adults who do not possess enough autonomy to be violated. Similarly, actions or policies undertaken to benefit others or protect them from harm do not count as paternalism. This is true even if the one who is the target of the action also benefits in some ancillary way.

Similarly, actions taken to protect the welfare of those who are so addicted to a chemical that their actions are not substantially autonomous are not rightly considered paternalistic (Faden et al. 1986). There is no substantial violation of autonomy.

The term “substantial” is important. It recognizes that people and their actions are not rigidly classified as either autonomous or nonautonomous. Autonomy varies by degree and by the nature of the decision being made (Buchanan and Brock 1989). Autonomy is sometimes said to be a “threshold concept” (cf. Buchanan & Brock: 26-29). People are thought either to possess enough autonomy to make choices on their own, in which case they can be said to be “substantially autonomous,” or they fail to reach the threshold, in which case they can be said to be substantially nonautonomous.

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