Autonomy and Paternalism

Devisch I (2011) Progress in medicine: autonomy, oughtonomy and nudging Journal of Evaluation in Clinical Practice 17 5 857-861

Devisch (2011) attempts to deconstruct what she calls a false dichotomy that exists between paternalistic behaviour and individual autonomy and proposes a middle way. The premise of her argument is that autonomy does not exist in a vacumm but is contingent on external influences that overlay individual decision making. To support this she uses the example of obesity and the many social and environmental factors from advertising to availability of inexpensive junk food to the positioning of candy at eye level at grocery store checkouts. These influences converge to influence individual autonomy. She offers the concept of ‘nudging’ over paternalism, a middle road that changes these external influences, to support autonomy by limiting but not removing choices. Devisch (2011) goes further, suggesting that these influences, the marketing of unhealthy lifestyles, are constructions that ‘contaminate autonomy’, heavily influencing choices. She suggests ‘nudging’ is a means of altering this context of choice, or as she puts it, ‘improving our choice architecture’ without imposing restrictive legislative measures.

This article explores autonomy and paternalism and healthy lifestyle choices and barriers out with the clinical setting and as a philosophical debate. However, she fails to address the practicalities of such changes, who would be responsible for implementing and overseeing them? Such a move would necessarily involve legislation and public policy implementation that impacted advertising, product placement in supermarkets and portion sizes in fast food restaurants and cinemas (popcorn). This brings the argument full circle with regards to autonomy. It also fails to address the social and environmental structures that create and perpetuate poverty, and thus impact health