In general, paternalism is presumptively wrong when it is directed at a person who is capable of making autonomous decisions on her own. And paternalism is not presumptively wrong when it is directed at a non-autonomous person. One way to interpret the relationship between paternalism and autonomy is that if two people have the same capacities to make decisions, then they ought to be subject to or protected from paternalism to the same degree. Let’s call this view Similar Paternalism:
Similar Paternalism: People should respect non-autonomous older people’s decisions to the same extent that they respect similarly non-autonomous young people’s decisions. Paternalism towards older people is as morally risky as paternalism toward younger people.
Similar Paternalism is partly justified by the desiderata that like cases be treated alike. It's generally good if people’s moral status does not depend on normatively extraneous, contingent factors (such as age, ability, or life stage). On this view, if an older person and a young person are equal with respect to their ability to make decisions, then they also are equal with respect to their entitlement to not be treated paternalistically.
This view stands in contrast to two alternatives. Call the first alternative Youth Paternalism. This view holds that paternalism toward young people is easier to justify, holding constant a person’s capacities, than paternalism toward older people:
Youth Paternalism: All else equal, people should respect non-autonomous older people’s decisions to a greater extent than similarly non-autonomous young people’s decisions. Paternalism towards older people is more morally risky than paternalism toward younger people.
Most people who disagree with Similar Paternalism will resist this view on these grounds. There are several justifications for Youth Paternalism. First, older adults may have previously made autonomous choices that would weigh against paternalism, such as issuing advance directives. Also, older adults may have acquired a kind of dignity, in virtue of having been autonomous in the past, that weighs against the justifiability of paternalism. And older people may have life plans, set in place in the past, that prohibit paternalistic treatment in ways that similarly capacitated young people do not. Or, it may be that paternalism toward older people is presumptively worse simply because it is more likely to misfire or be counterproductive.
I think that both Similar Paternalism and Youth Paternalism are mistaken because paternalism toward young people is, all else equal, less justifiable than paternalism toward similarly capacitated older people. Call this view, Elder-Paternalism.
Elder Paternalism: All else equal, people should respect non-autonomous older people’s decisions to a lesser extent than similarly non-autonomous young people’s decisions. Paternalism towards older people is less morally risky than paternalism toward younger people.
Against Similar Paternalism, I agree with the youth paternalists that when assessing the permissibility of paternalism, it not only matters how autonomous a person is, it also matters whether their autonomous capacities are rising or declining. The problem with similar paternalism is that it fails to include all the information about a person’s autonomous capacities that would be relevant to decisions about whether, in virtue of their autonomy, paternalism toward someone is warranted.
But against Youth Paternalism, I think that choices made by people with declining capacities merit more respect. I think this for three related reasons. First, if a person’s autonomous capacities are rising, then paternalistic interference is more morally risky than it would be if their capacities were declining because, to the extent that paternalism operates over time, there is a greater risk that it will eventually violate an autonomous person’s right against being paternalistically interfered with.
Second, interfering with a person whose autonomous capacities are rising can also be morally risky because it can impede the development of her autonomy, whereas that is not a consideration for a person whose capacities are in decline.
And third, to the extent that a prohibition on paternalistic interference is grounded in the value of respecting the value of people’s autonomous capacities or quality of will, there is a sense in which younger people, in virtue of their rising or accelerating autonomy, do have more metaphysically robust autonomous capacities than older people who are similarly capacitated at a given time.
This is not to say that it is generally OK to treat older people paternalistically. I suspect that there’s too much paternalism toward children and toward older people. My claim here is just about the relative strength of a presumption against paternalism for older people and children. If I’m right, then caregivers and policymakers are making a mistake when they assume that paternalism towards children is a paradigmatic case of justifiable paternalism, or when people suggest that interference with children’s choices is the least morally risky kind of paternalism.