Caring, patient autonomy and the stigma of paternalism.

This paper utilizes data generated during a qualitative study in palliative and maternity care settings to guide discussion of the current discourse, which emphasizes patient autonomy and derides paternalism. Data are presented which illustrate that this ideology is established in nursing practice. Respect for patient autonomy is identified as an essential element of individualized, patient-centred and ethical care but conversely, it is suggested that overemphasis may confuse and suppress beneficent intervention. The value of ethical theory to provide an objective means to explore ethical dilemmas in practice is not debated, but exploration of the issues raised by the data suggest, that principle-based ethical theory suffers the following constraints: the predetermined balance of ethical principles in favour of respect for autonomy prevents an unbiased perspective and optimum guidance; in contrast to caring relationship, application of ethical theory does not reveal the particulars necessary to guide ethical decisions aimed at promoting good for the individual; current discourse appears to disregard the inherent inequality in the relationship between the helped and helper and practitioners' need to preserve their own moral integrity. Consequently, this paper argues that beneficence derived through caring should not be superseded uncritically and suggests that mutual nurse-patient relationship, which balances respect for patient autonomy and beneficent guidance based on practitioner's clinical expertise, protects the moral integrity of both patient and practitioner. For conciseness, the term patient will be used to indicate recipients of both nursing and midwifery care and while both nurses and midwives are not always specified, any term referring to nurses, denotes both.