Saturday, December 24, 2005

"Respect for persons entails dialogue, perhaps even confrontation, but only to ensure honesty in each party, in the face of death."

The December Journal of Medical Ethics has an opinion piece questioning the teaching of the "Four Principles" (beneficence, non-maleficence, autonomy, and justice) to medical students.  In fact, it generally savages the 4 principles all around (not so much for the ideas themselves but for the their promotion as bedrocks of ethical medical decision making).  The piece smacks somewhat of a medical ethics in-fight, but the author has some choice things to say.  I appreciated the article for a few reasons: 1) I whole-heartedly agree that the 4 Principles are just not very useful--when was the last time you consulted them to help you think about a difficult case? 2) "autonomy" is often misused by physicians as a way of avoiding making difficult decisions about medical care with their patients (cf. the Hastings Center Report, 3rd article, by R. Burt), & 3) for its contrarian rhetoric & use of the word "palaver."

Some highlights...
[The Four Principles] remain utterly fatuous. Let me take the two neologisms first. What does beneficence mean other than "be nice"? What does non-maleficence mean other than "don't be nasty" (however noble sounding the Hippocratic Oath)? Such heavy-sounding principles are hardly going to enlighten anybody, let alone solve ethical puzzles. After all, every time I give an injection I am harming the patient. Instead, there are perhaps two sets of genuine ethical questions that are needlessly obscured by the bureaucratic verbiage: (i) is this action really harmful, in what sense, according to what criteria, in whose judgment, is the response to the harm appropriate, etc, and (ii) is this harm justified by the quality and likelihood of the subsequent benefit? My point is: if these are the real questions, why not go straight to them, without all the palaver?

Some have claimed that the Four Principles could act as a structural framework for analysis or "a useful 'checklist' approach to bioethics for those new to the field".  I would say that anybody who is morally obtuse enough to need such a checklist would not be capable of interpersonal relationships of any complexity, and certainly should not be practising medicine.

Autonomy is more philosophically robust than the first two, but it is no philosophical achievement to conclude that "X should be done because it respects the patient's autonomy". When a competent patient declares what he wants or does not want, then of course this should be respected where possible: but that's not a high blown Principle of Medical Ethics, that is how we should treat anybody. Again, the real ethical questions are unnecessarily obscured: should the patient be given what he wants when there is a doubt about whether he understands his situation and the options available? Should the patient be given what he wants when it is judged medically futile? Too much emphasis on autonomy leads to a conception of health care as merely another service to be provided to customers on demand. In this I agree with Alastair Campbell, who prefers to speak of respect for persons rather than respect for autonomy: "Respect for persons entails dialogue, perhaps even confrontation, but only to ensure honesty in each party, in the face of death".

And on this note I wish Pallimed's readers Happy Holidays & Safe Travels.


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