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I am grateful to the Journal of Medical Ethics for asking these critics to discuss my book, and am grateful to each of the critics themselves for raising interesting and often difficult issues for me to think about.
Alan Wertheimer makes a number of good points. One of the most significant, to me, is how paternalism might function at what I will call an institutional level. In my book, I endorse paternalistic actions by the state, when the cost benefit analysis justifies that. I have not supported paternalistic interventions by private individuals, though. For one thing, private individuals will make decisions without public input, and without their justification being examined by experts in the field, and for these reasons they are too likely to make mistakes as to when intervention is appropriate. For another, the interventions by random individuals haranguing us about our failure to eat our broccoli is likely to drive us crazy—unexpected interference from people with no particular authority will give us just that sense of harassment I say paternalists need to avoid.
However, between the public, authorised actions of a democratic state and the private actions of individuals with no authority lies the significant area of non-state institutions. Such institutions develop regulations and standards their members are expected to act in accordance with, and these in turn can have a significant impact on private persons. Of course, there have also been legal actions, notably court decisions, that have played a role here, but much of the specific interpretation of things like consent has been determined by the medical community developing what it believes to be an appropriate ethic for itself. And we know, here, that in recent years there has been a movement away from the paternalism that was once common, and a reorientation towards respect for …