1 Introduction

In this second part of the special issue, Anna Hirsch and Birgit Beck each tackle further conceptual questions about paternalism and discuss their practical impact. In her contribution “Relational Autonomy and Paternalism—Why the Physician-Patient Relationship Matters,” Anna Hirsch discusses the particular challenge of paternalism when considered against the conceptual background of relational autonomy in medical ethics. While both the concepts of paternalism and relational autonomy are much discussed in medical ethics, they are usually addressed separately. Hirsch’s contribution aims at remedying this separation and discusses them in their interrelation. Accordingly, the main question is how the understanding and justification of medical paternalism may change if we take a (constitutively) relational understanding of autonomy as basis. From an individualistic understanding of autonomy, medical paternalism interferes with the individual sphere of a patient. Hence, it can only—if at all—be justified if the benefit to the patient outweighs the extent of the violation of their autonomy. However, according to a relational understanding of autonomy, Hirsch argues, other justification criteria come to the fore than those we know from the ‘classic paternalism debate.’ Building on the concept of maternalism introduced by Laura Specker-Sullivan and Fay Niker (Specker Sullivan and Niker 2018), Hirsch proposes that the nature and quality of the physician-patient relationship, the epistemic access to the patient’s pro-attitudes, the physician’s motivation to intervene, and intersubjective recognition constitute relevant justification criteria. In addition, she argues that these criteria provide helpful indications of how physician-patient relationships should be structured to enable relational autonomy in patient care and avoid medical paternalism in general.

In her contribution “Paternalism and Liberty/Autonomy as Dialectically Related Concepts,” Birgit Beck also focuses on the notion of autonomy but addresses its interrelation with the concept of liberty. Following the seminal definition by Gerald Dworkin (Dworkin 2020, section 2), paternalism comprises interventions that interfere with a person’s autonomy or liberty, lack the concerned person’s consent, and are conducted with benevolent intention. Against the background of a paper by Dominik Düber (Düber 2015), who advises to abstain from applying the notions of liberty and autonomy in a conceptual analysis of paternalism to avoid conceptual confusion and moral preconception, Beck argues to the contrary that the conceptual differentiation of paternalism along the lines of liberty and autonomy does not anticipate moral appraisal of paternalism. Instead, it reveals dialectic conceptual relations between the concept of paternalism and the concepts of liberty and autonomy, respectively. Beck goes on to argue that, depending on the presumption of paternalistic interventions as interfering with liberty or autonomy, paternalism amounts to a binary concept or a gradual concept. Likewise, depending on the concepts of liberty and autonomy, the need for legal and/or ethical justification as well as the weight of the burden of justification for paternalistic interventions vary. As her analysis indicates, the conceptualization and justification of paternalism, therefore, requires complex conceptual and (meta-)ethical considerations on different levels of argumentation, just like practically all instances of ethical deliberation.

All four papers of this special issue thus shed further light on the complexity and intricacies of how to analyze potentially paternalistic interventions versus respecting people’s autonomy and liberty, and how different varieties of paternalism might be justified or rejected on different (theoretical) ethical grounds. Accordingly, following Beck’s line of argument more generally, both the conceptual analysis and the ethical assessment of specific cases hinge substantially on which combination of well-known conceptions of paternalism (hard vs. soft, strong vs. weak etc., cp. Dworkin 2020, section 2), on the one hand, and specific conceptions of personal autonomy (esp. individualist vs. relational, cp. Christman 2020), on the other hand, is presupposed. Moreover, any attempt at justifying paternalistic interventions must clarify the role of personal autonomy within the concept of human well-being and whether this role allows for being outweighed by other aspects of human well-being.

For instance, the traditional utilitarian-based debate, which assumed a purely individualist conception of personal autonomy and assigned a person’s autonomy a primary role in her overall well-being, has led to a clear rejection of hard paternalistic interferences. Consequently, utilitarian proponents of paternalism either had to revert to soft or nudge paternalism and claim that these conceptions are perfectly compatible with respecting people’s autonomy or even enhancing it, and thereby also people’s well-being, or had to argue that autonomy should not be assigned priority in people’s well-being. However, the latter option conflicts with utilitarian based liberalism, seminally upheld by John Stuart Mill (Mill 1977 [1859]).Footnote 1

Yet, once one abandons an individualist conception of personal autonomy in favor of a relational conception, it becomes less clear where—morally justified and even welcome—social contributions to developing, maintaining, or even supporting a person’s autonomy end and—morally problematic—paternalistic interventions begin, as, e.g., Hirsch has shown in her contribution in the context of medical ethics and Mitrović and Mitrović in their historical overview of paternalistic practices in part 1 of this special issue (Mitrović and Mitrović 2023).

In sum, as the four contributions to this special issue have shown, the debate about paternalism strongly benefits from making explicit and discussing head-on the conceptual and ethical intricacies and implications not only of each conceptual and phenomenal component separately but also especially in their various theoretical and practical combinations. Consequently, the debate about paternalism is far from over and still leaves ample room for further contributions.