Whenever I hear the term ‘paternalism’, it strikes me how bad a metaphor it has become for describing the mechanics of authority. Does the figure of the father — individual, domestic, affect-swollen — provide the right frame for thinking about the increasingly diffuse and bureaucratic vectors of power that political, economic, pedagogic or psychiatric actors use? On the whole: no (as I have written about before).
If the prospects of paternalism as an analytical tool are rather dim, then it’s chances as a normative ideal are, of course, even worse. For instance, Corey Robin has recently underlined the way that appeals to fatherly authority act as unifying force in conservative politics:
[C]onservatism is a defense of “the private life of power,” those hierarchies in spheres like the family and the workplace that we often call private. […] People often wonder how libertarian-ish free market types can come together with cultural and religious conservatives in the GOP. [T]he answer: Both groups value the power of fathers—in the family, and in the workplace.
Nor does it seem too crass to note the association between the valorisation of paternal forms of authority and proto-fascist sympathies. In short: it’s hard to imagine someone telling me that they thought fatherhood was a good way to think about how authority should be used and not immediately thinking they were some kind of reactionary idiot.
Despite these analytical and normative limitations, I wonder whether paternalism can be put to some sort of use in thinking about techniques for legitimating authority in psychiatry and social care. Again, I am usually wary of the concept even in this context, since it’s so ill-fitting in care relationships. When the paradigm form of medical care was the male doctor, practicing alone in a community where he commanded great respect and had cultivated social relationships with most of his patients, then the paternal metaphor seems more apt. But when care is now so often ‘delivered’ by multidisciplinary teams, directed by institutional bureaucracies, which are bound by more aggressive forms of central oversight and control, in the context of huge resource allocation pressures and a tendency toward defensive medicine, then the relationship between father and child looks to be much less illuminating. All metaphors give out somewhere along the line, of course. In this case, however, given how common it is to hear the language of ‘paternalism’ (almost always wielded as a criticism), the mismatch between it and the phenomena described is problematic. We need new metaphors — not least, to stop thinking about authority in care settings getting stale.
This being said, I want to see whether paternalism can be put to work, albeit in an admittedly weird way. Paternalism is an analogical concept: it maps a relation father-to-child onto another relationship, e.g. government-to-citizen, psychiatrist-to-patient, teacher-to-pupil. The relation I want to examine under the concept of paternalism is unusual in that the same person occupies both places. In other words, what if the father-to-child relation is mapped onto a relation of a person-to-themselves? Can you be paternalistic towards yourself?
In its bare-bones form, paternalism is interference with a person’s liberty intended to promote their own good. This meshes with the idealisation of fatherhood as a relation to a child of superior knowledge and power alongside benevolent intentions. This father wants what is best for the child, usually knows what that is better than the child does, and is able to bring it about by imposing his will. Thinking about my proposal, what then would it even mean for you to know what is good for you better than you do yourself? How can your impose your will on yourself? These can seem like contradictions in terms. Thus, paternalism towards oneself threatens to be nonsensical.
There are activities in psychiatry and social care that exemplify this structure, however. For example, making what is called an ‘advance decision’, in which a person who currently has legal capacity to decide for themselves makes a binding judgement about what should happen to them should they be found to lack decision-making capacity. For instance, this person might want to refuse certain medical treatments in advance before their dementia makes it legally and practically difficult to object.
This is possible because you both are and are not the person you once were. In other words, people are temporally extended without being static. In an advance decision, someone takes themselves to be better placed with respect to knowledge, power and self-concern now than they will be in the future. This might even involve restricting the liberty of their future self in what a person deems to be their own best interest. For example, if the future self lacks mental capacity and wants treatment that the care team would have otherwise given them if not for the advance decision, then current liberty is restricted on the basis of benevolent self-directed intentions. In an immediate sense, the person’s liberty is being restricted by the care team; but the care team are acting as agents of the former self. In this way, the self binds itself in what it takes to be its own best interests.
This structure is also found in some collaborative emergency care plans in psychiatry (where advance decisions are typically not valid). These involve the person themselves in planning the response ahead of time when it’s likely that someone is going to end up ‘losing the plot’ — for instance, before the manic phase of bipolar disorders kicks in. Again, people are being invited to think about how to restrict their future liberty for their own good. (George Szmukler and colleagues have written more about the use of these ‘joint crisis plans’.) Yet another example might be residential care homes for people with Prader-Willi syndrome, which I discuss in this post.
One way to think about what is going on here is to rely on the paternalism metaphor. People are being asked to adopt a similar perspective with respect to themselves as parents often do towards their children. How do you help someone’s life along, or make sure it doesn’t end in disaster, without smothering them with your parochial hangups? In our case, the exercise of power is to be legitimated or at least mitigated in light of a superior knowledge and self-concern that can be made effective through institutional power. The assumption would be that you know yourself and what is in your own good better than anyone else and better than your ill or otherwise incapacitous self. Plus, it supposes that you actually want to bring it about. Both are contestable, of course, but are prima facie plausible.
If you were your own parent, how would you construct the regime of power in which you are to live? Do you give yourself maximum scope to go your own way, risk making mistakes, and live in the moment, or do you make sure that someone you trust has a firm hand on the tiller, even if that means they sometimes force you to do things you don’t want to? The task is a little like trying to plot your own Bildungsroman, only in reverse — a kind of Verbildungsroman, or story of deformation. Given that parts of your self are going to slip away, either temporarily or permanently, the task is to shape the trajectory of that decline when you seem best able to do so. How to accomplish this isn’t clear: there’s likely to be conflicting impulses to junk as much authority as possible and to micromanage your future in a way that allows no scope for development or changes of mind. At least one approach to this task is to ask what would someone do who cared about you in the way that parents typically care about their children. This might provide some useful initial cognitive traction on the problem. I’m still far from sure this is the best way to think about these ‘Ulysses contract’ structures; but the concept of paternalism may be more fitting here than in its more familiar uses.