In the results of the 2007 survey, GPs and surgeons, together with the middle aged (46-60 years) and the oldest physicians (>61 years), had low (or in the case of the oldest physicians, very low) degrees of disguised paternalism (that is, their indices are well over the 0.38 average). Geriatricians, internists, psychiatrists and oncologists had high degrees of paternalism (as indicated by indices less than 0.38), while the youngest age group (<46 years) had very degrees of disguised paternalism (as indicated by the negative index value).
Analysis of the 2020 survey results revealed a somewhat different pattern of disguised paternalism among the specialties. GPs, surgeons, and psychiatrists had low degrees of disguised paternalism, as did the youngest group of physicians and the oldest group of physicians (all above the 0.21 average). Internists, oncologists, and the middle-aged group were slightly below the average, indicating a high level of disguised paternalism, while geriatricians, palliativists had negative indexes, indicating that the physicians in these two specialties had quite high degrees of disguised paternalism.
Comparing the 2007 indices to the 2020 indices, we can see that the groups that changed the most in terms of relative amounts of disguised paternalism are geriatricians, psychiatrists, and the youngest physicians. Geriatricians were less paternalistic in the 2007 study than the 2020 study; in contrast, psychiatrists and the group of youngest physicians were more paternalistic in 2007 than 2020. The main results of the 2020 study showed that most specialties, with the exception of geriatricians, were more pro-PAS in 2020 than they were in 2007 (9). (In the 2020 study, a majority of palliativists were against PAS, but no comparison to 2007 is possible.)
Comparing the age groups, we see that in 2007, the youngest group of physicians had a high level of disguised paternalism, while the middle-aged and oldest group did not. In 2020, the middle-aged group had a high level of disguised paternalism, while the oldest and youngest did not. Of course, many individual physicians who were in the youngest group in 2007 have aged into the middle-aged group in 2020. If this trend continues, we might expect that a survey performed in 2033 would reveal that middle-aged physicians (i.e., today’s young physicians) would have a lower degree of disguised paternalism than today’s middle-aged physicians.
Geriatricians and palliativists
The most relevant result for discussing PAS and other end-of-life issues is the high level of disguised paternalism among geriatricians and palliative care physicians. In 2007, this specialty had a high level of disguised paternalism, but in 2020, the index became negative, indicating an even higher degree of disguised paternalism. This trend in this specialty might reflect a reaction to the ongoing covid-19 pandemic, where many elderly and frail patients, sometimes also cognitively impaired, died under conditions that, under normal circumstance, would have meant they would have been offered to palliative care (10) – even the dysphemism “euthanasia” was used in the Swedish debate when discussing elderly patients with covid-19 (11). The majority of these patients would not have been referred to emergency hospitals under normal conditions, but during the pandemic, not treating patients suffering from covid-19 pneumonia was considered to be a type of assisted dying (11). The use of terms like ‘palliative care’ and ‘euthanasia’ might have influenced geriatricians and their attitudes towards the PAS issue, and stressed the importance the non-maleficence principle. Some of the geriatric patients may have been physically frail with several comorbidities, but still mentally competent, and we do not know what they would have preferred. Some of these patients might also have a dementia diagnosis, and it is possible that geriatricians were trying to protect these non-competent patients. When patients are not competent and the physician makes decisions on their behalf, this is referred to as soft paternalism. Disguised paternalism is not about soft paternalism, but rather about hard paternalism, and disguised paternalism is actualized when, for instance, a geriatrician transforms hard paternalism to soft paternalism by considering a competent patient as non-competent as a way to justify their decisions.
The other specialty with very high disguised paternalism index was palliativists. Palliative care physicians take care of many suffering patients at the end of life, and seems reasonable to ask whether this disguised paternalism influences decisions made by these physicians. There are indications that palliativists’ personal values influence whether or not they apply palliative sedation (1, 4, 12), which is particularly relevant because “good palliative care” together with palliative sedation is often claimed to be an adequate or even better alternative to PAS (10). An international trend is that palliativists are currently more inclined to provide continuous deep sedation on a patient’s request (13, 14). But this trend is not yet observable in Sweden, which is problematic because continuous deep sedation on request could in many (though not all) cases replace PAS (15). Some palliativists seem to have not only disguised paternalism, but also the form of paternalism in which they claim that they are protecting a patient’s autonomy rather than respecting it. Since such palliativists are referring to autonomy, their attitude becomes paternalism in the in the name of autonomy, which is a sophisticated form of disguised paternalism (16). In practice, a patient might request continuous deep sedation, but it order to protect the patient’s autonomy, superficial and intermittent palliative sedation is provided instead, even against the patient’s preferences (5). Such a patient might be brought to consciousness up to four times per day in order to be asked whether or not they would like to continue being sedated (1, 4). Representatives from the general public have described such procedure as macabre or cruel and non-humane (17).
As can be seen from (especially) palliativists, disguised paternalism might have serious consequences for patients within palliative care. If such patients are truly competent, their wishes and preferences at the end of life should be respected. The 2020 study indicated that one in four palliativists supported PAS, which still leaves a clear majority against PAS, and it has been shown that palliativists’ personal values influence their practice and their regard for patients’ wishes (1, 4). Disguised paternalism is not solely an academic issue – it has consequences when equal cases are not treated equally – and, accordingly, disguised paternalism should be revealed when possible and counteracted.