The search for reasons in a unified relationship.

The paternalism, autonomy debate was influenced by traditional ideas that reasons are either objective (based on values existing independent of any particular person) or subjective (based on values tied to individual's personal histories). This dichotomy has been rewarding for the health care community. However, the tenets of this debate have influenced the nature of deliberation in a way that seriously compromises the ability of health care professionals and patients to bring reflection (the search for justified reasons) to a successful end. It sets up the moral landscape not as one of unity and reciprocity, but as one of divisiveness and distance-where one person (the physician) does something to another (paternalism) or for another (patient autonomy), rather than with another. This distance and divisiveness undermines the unity of wills and genuine reciprocity that I argue is indispensable for genuinely good relationships and necessary for successfully establishing what reasons there are to act. It has created an abyss in communication that even recent suggestions for change cannot bridge. In this paper, I discuss the nature of this abyss and the problems it has created by demonstrating that traditional theoretical ideas about the nature of reasons have influenced the nature of deliberation in health care. I argue that recent suggestions for "justified paternalism" fail to bridge the abyss. Finally, I suggest that to be successful, we must change the framework; we must reject the ideas of objective and subjective value and embrace instead the idea that values are intersubjective.