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Back to Basics in Bioethics: Reconciling Patient Autonomy with Physician Responsibility
Antonio Casado da Rocha*
University of the Basque Country
Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient-doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonas’s philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub-fields in bioethics, the resulting model claims that physician responsibility is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatch’s contractual model.
1. Introduction According to prominent bioethicists such as Peter Singer, Edmund Pellegrino, and Mark Siegler, the major contribution to the philosophical foundations of clinical ethics has been the continued refinement of Principles of Biomedical Ethics, by Tom Beauchamp and James Childress (originally published in 1979; sixth edition, 2008). However, after more than 20 years of clinical ethics those authors acknowledge that its main focus of interest – the doctor-patient relationship – is ‘in worse shape than it was when the field began’ (Singer, Pellegrino, and Siegler). The doctor-patient relationship describes the interactions between these two players and shows huge divergences across different cultures and societies, but a main theme in the literature about it during the 1990s in the USA was that of bureaucratization by managed care, a problematic attempt of health service modernization that has been reflected in other countries, such as the UK (Degeling et al.). A relationship which used to be a personal one is now dominated by medical technologies and bureaucratic procedures. As a result, patients and health care professionals have become ‘strangers at the bedside’, to use the title of David Rothman’s classic book about this subject. If Singer, Pellegrino, and Siegler are correct in their diagnosis, it is ironic (and worrisome) that the doctor-patient relationship is deteriorating
© 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd
he rejects the idea of medical ethics usually understood as applied ethics. This is the case with Alfred Tauber. generally by arguing that in bioethics there is a bidirectional. bioethicists are aware of this situation.2 Back to Basics in Bioethics at a time when the field of bioethics has experienced an impressive progress. So there seems to be a divorce. in which the patient’s own values play a robust role in framing accounts of medicine (Veatch. and have often framed it as a debate over whose values ought to guide the doctor-patient relationship. there is little literature on the concept of responsibility in bioethics (see Turoldo and Barilan for a comprehensive account of its development). We have. 420). this view has been criticized on several fronts (Baker and McCullogh). Of course. Philosophy textbooks typically treat bioethics as a form of ‘applied ethics’ – an attempt to apply a given ethical theory to controversial moral issues in biology and medicine.2008. but there is still a lively discussion about what should be the central paradigm upon which medical bioethics is based. many important authors in this field have combined careers in medicine and philosophy. not only in America but also in Europe. between patient autonomy and an ethics of responsibility. and in providing a sketch of a philosophy of medicine true to its intrinsically ethical nature – what he calls a ‘moral epistemology’ and has developed in his book Patient Autonomy and the Ethics of Responsibility (2005). Those are attempts to maintain professional integrity in the face of moves towards a medical consumerism which threatens to reduce clinicians to technicians. Should there be reconciliation? To date. dynamic process of ‘appropriation’ or exchange between theory and practice. for instance. However.1747-9991. By drawing mainly on Tauber’s two books on this issue.1111/j.x . While the history of the doctor-patient relationship has often been read as a successful battle for patient autonomy and against medical paternalism couched as beneficence. ‘How Philosophy of Medicine Has Changed Medical Ethics’.00190. He is more deeply interested in ‘medicine becoming more self-consciously moral’ (93). who has published widely in the intersection of these fields. and Jotterand 566). and the more recent effort by Margaret Brazier to dethrone the ‘great god Autonomy’ by arguing that patients should bear responsibilities as well as rights. Garrett. now complicated by amazing technological developments in the science of curing. and to render medical ethics otiose (Brazier 398. an increasing gap. In his award-winning book Confessions of a Medicine Man (1999). born in 1947. both socially and academically. Some authors argue that we have entered a postmodern era. Onora O’Neill’s emphasis upon trust and beneficence as opposed to autonomy. Engelhardt. as a tool to clarify the responsibilities of health care professionals. attempts to curb autonomy’s expansion as the hegemonic value in bioethics are being mounted today. After all. the following sections will summarize his argument that the principle of respect for autonomy – one of the four principles popularized by Beauchamp and Childress – cannot be divorced from the responsibility health care professionals © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10.
the history of modern moral philosophy culminates in the ‘invention’ of this idea of autonomy. and of. Because autonomy was then associated with individualism.00190. and sought to replace it with a comprehensive self-responsibility. fathers of Anglo-American medical ethics such as Gregory. But first let us have a look at how the separation took place. For autonomy to become the flagship of modern ethics. and Rush.x . traditional sources of authority had to recede. understood as self-reliance.Back to Basics in Bioethics 3 assume in the care of the patient. 2. and by itself ’ (Tauber. offering a rich template for defining personal identity with a particular emphasis on self-responsibility. independence and autonomy. Autonomy and Responsibility: Anatomy of a Divorce Traditional ethics stressed responsibilities toward others in small societies governed by a given communal morality. Modern medicine became defined by specialization. and so the ethical nature of our responsibilities toward others. The latter denounced traditional Christian ethics as ‘masks of illusion’. on the other. Thus in the 19th century a split was formed in the way we understand our selves: on one side. no unique code of professional ethics was required for medicine until the end of the 18th century. rapid technological advance. they did so with a strong leaning toward individual responsibility for others. Kant’s philosophy can be seen as a response to the moral philosophy of the preceding two centuries by unfolding the central notion of morality as self-governance.2008. Patient Autonomy 93). Because autonomy was central to modern ethics. This situation dramatically changed in the 20th century. toward God’ (Tauber. exposing the treachery of belief in a stable and universal morality ‘out there’. respectively. embraced the Scottish enlightenment notions of self-improvement as central to their profession and self-image. relation and responsibility. and authenticity (Tauber. According to Schneewind. Of course. but this changed in 18th-century Europe. Patient Autonomy 69). and. so when ‘they identified as part of a profession. and a profit-driven industry © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. responsibility was marginalized. as exemplified by the philosophy of Emerson and Nietzsche. In the old days. in which rational beings are subject to a moral law because it derives from them. moral responsibility became a one-person business.1747-9991. and that patient autonomy often does (and ought to) give way to other principles present in biomedical ethics. such as beneficence. reliance on medical technology increased and patients’ trust in doctors steadily declined. toward the community at large. Percival. of course. The former ‘became a conduit of Protestant theology into a nonsectarian world’. the ‘nihilistic assertion that the self resides in. As the influence of clergymen waned. self-direction. Confessions of a Medicine Man 37). And indeed this happened in 19thcentury America and Europe. this change had consequences in the way health care ethics was conceived of. As a result.1111/j.
Tauber suggests that the cultural hegemony of individualistic autonomy is especially problematic when introduced in the health care relationship. as Jonathan Moreno put it (‘Triumph of Autonomy’ 416–18). being ill can be regarded as a negative judgment. But Tauber reminds us of the negative one as well: because autonomy-based moral systems emphasize individual responsibility for one’s health. caring. On the contrary side. as a stigma. which witnessed a radicalization of health-related rights and political issues.4 Back to Basics in Bioethics (Imber). In the early 1990s. and self-realization’ (Patient Autonomy 118). in a prevailing communal ethos the focus is on reciprocity of care.1111/j. a doctor observed that the health care relationship is usually understood as a relation ‘between citizens in the liberal state’. Wade decision are some of the main events that pushed autonomy to the fore in this period. and self-consuming narcissism’ (Tauber. and thus ‘the idealized autonomous person forfeits trust. friendship. On the other hand. The concept of autonomy occupies today a central role in the legal and ethical frameworks governing clinical practice. because its ‘positive ethic of self-responsibility and self-realization can easily tip over into “selfishness”. “autocracy”. The reason why is that self-sufficient independence promotes self-reliance over relationship.1747-9991. the typically Nietzschean disregard for others is not acceptable as a foundation for health care ethics. the hegemony of individual autonomy is asserted in all domains of American society.x . particularly but not exclusively in the context of western health care (Slowther). By the late 1960s and early 1970s bioethics was born and legitimated in and by North American institutions. In other words. the Tuskegee scandal. corporate interests benefited the most from the increased sophistication of medical consumers who insist on exercising their ‘autonomy’. and the Roe v. leading bioethicists such as Robert Veach (Patient-Physician Relation) see nothing wrong with it. © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. some authors have described autonomy as ‘first among equals’ (Gillon). At the beginning of the 21st century. loyalty. and therefore it is not adequate to expect from its morality anything more than ‘a simple “contract” between two autonomous people’ (qtd.00190. The Present Paradigm: Factual Commercialized Health Care What is the problem with individual autonomy? After all. in Imber 14). Although Beauchamp and Childress did not postulate a hierarchy of principles. and responsibility as secondary attributes to those primary values of self-direction. and because disease destabilizes our sense of self. not by a particular type of relationship or professional responsibility. arguing that bioethics should adapt to our individualist ethos by embracing a contractual model in which all parties have an equal standing. and extended the legal domain of personal moral choice. there is a positive side to the ethics of autonomy: it provides a sense of empowerment in terms of political rights. self-determination. 3. Confessions of a Medicine Man 41). the Karen Quinlan case.2008. In the following decades. Of course.
which itself is a psychological or social product of moral engagement and. emptying medical practice of its intrinsically moral character.00190. i. according to Tauber (Patient Autonomy 192). Patient autonomy has assumed a defensive character as patients increasingly wonder. it models a way of looking at medicine that sees it as a business dealing mainly with facts. physicians neglect their full moral responsibility. thus creating mistrust. as we will see now. The autonomist model has dominated bioethics through legal and commercial interpretations – one focused on rights. but © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. This general problem expresses itself in many ways. (159) This commercial medical economy often has demands that go against an ethics of responsibility. the Quinlan case of 1975 represented a critique of traditional medical ethics. the other on market forces requiring free choice of ‘purchase’. 161–2. one which has improved the ethical standards of good medical practice. by establishing that physicians were authoritative about ‘medical facts’. plays a crucial role in the health care relationship between patient and professional (181.e.. Confessions of a Medicine Man 47. ‘Will my doctor do what is best for me?’ An ethics of responsibility is needed as a foundation for the trust/mistrust phenomenon.Back to Basics in Bioethics 5 Individual autonomy is a bad model for health care ethics because its contractual underpinnings induce us not to acknowledge the deeply inequality of the power relationship between physician and patient (Tauber. And. or with facts as something radically separated from values. Confessions of a Medicine Man 22–3). As it will be immediately explained. patients have become ‘consumers’ and doctors ‘providers’ of health care: The purchase of care. 4. Patient Autonomy 126). As for the first one. But this merely factual. detached attitude of the physician qua natural scientist prevents a comprehensive understanding of the ‘whole person’.2008. As for the second one.1747-9991. informed consent is an important practice in contemporary medicine.1111/j. but not necessarily expert or autonomous regarding ‘moral values’. as it will be explained in the next section. and without that engagement. that of facts.x . it promotes an understanding of informed consent as a merely legal safeguard. and generates mistrust both in the patient and in the professional. embedding their responsibility for making the delegated choices. the contractual agreement framing that commercial arrangement. and scientific expertise could not be extended beyond its proper quarter’ (Tauber. This case held that ‘decisions concerning medical care were situated firmly within the patient’s autonomous domain. and the resulting defensive autonomy adopted by the client are all products of a basic shift in the doctor-patient relationship from one dominated by a sense of personal commitment to a more distant and circumspect delivery of service. 171). Indeed. Mistrust and Informed Consent as Defensive Practices Informed consent is generally seen as an exercise of patient autonomy.
then. After all. as this reveals that the law recognizes the weakness of moral responsibility as a guiding ethos for the doctor-patient relationship. Mistrust goes both ways: according to Tauber. Care. Confessions of a Medicine Man 68. © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. does physician responsibility entail? In the following section. to include compassion and empathy in the interaction with the patient. and shared responsibilities to practice ethically. Patient Autonomy 138–40). we will see how responsibility should move professionals to recognize asymmetry in the health care relationship. hegemonic principle. But physician responsibility remains whatever degrees of patient autonomy are exercised (Tauber. the later lose the ethical grounding in their profession. Tauber is particularly dissatisfied with how it has become ‘a stopgap measure to protect against abuses of trust’ (Patient Autonomy 134. administrators. Towards Relational Autonomy: Asymmetry. as it might simply be a way to address the institution’s legal obligations and therefore protect it against malpractice suits. but not only that – it requires physician responsibility as well. the patients’ intentions and understanding remain the keystone of the consent process. 126). 60.2008. when patients do not trust physicians. and Self-Fulfillment Still recommended by some bioethicists as a partnership grounded in a complex contractual relation of mutual promising and commitment. not through fiduciary responsibility. It does not necessarily protect patient autonomy. directives. orders.x . In this respect.00190. What. thus offering the physician a strong defense or protection against malpractice suits. If there is a conflict between patient and physician. (Confessions of a Medicine Man 101) Autonomy is also a double-way street: true patient autonomy requires self-responsibility. the oft-quoted notion of ‘effective consent’ is mainly a legal one. or technocrats. to understand care as an opportunity for professional fulfillment. to integrate fact and value in a ‘moral epistemology’. they become so estranged from their patients that they must self-consciously seek guidance. and the responsibility for almost every choice remains theirs.1747-9991. Tauber finds it telling that a patient’s legal recourse is almost always channeled through charges of negligence. and autonomy as a quest for self-knowledge and for reflective equilibrium between moral principles – not as an exclusive. Consequently. as it is sometimes pictured today. If health care professionals identify themselves as health scientists. generally patient wishes must override other opinion.6 Back to Basics in Bioethics also one that has shifted responsibility to the patient. 5. providers. thus abandoning the contractual model. hence the institutional growth of medical ethics programs could actually be a sign that something is going wrong in the way medicine is practiced: the basic intuition of care as part and parcel of the health care professions is lost.1111/j. and in practice it often amounts to the mere signing of an informed consent form.
this is what made them doctors in the first place – and their moral responsibility is to exercise it in the effort to restore patient autonomy. As a matter of fact. and their exercise must be regarded as the fulfillment of any health care professional’s aspirations. one in which relational aspects of health care (such as empathy) are included. this activity is more difficult for the former than for the latter.1111/j. The disparity in expertise and the consequent compromise of patient autonomy for the sake of regaining health drive patients to delegate much decision making in the hands of the professional. (That is why we are particularly shocked when nurses distance themselves from the patient. What is needed is a different way of conceptualizing autonomy. Confessions of a Medicine Man 128 –9). but to be ill is already to admit that our selfhood has been compromised. most health care relationships are initiated by this very inequality or asymmetry. 38). This explains why the ‘guidance model’ is most typical and more adequate than the ‘contract model’. fidelity to promises made. Care and responsibility define what to be a doctor is.1747-9991.x . he claims that in the case of medicine they cannot be separated. because they do so precisely in the hope of regaining or improving their lost autonomy and equality. traditionally nurses have had fewer responsibilities competing with those private acts of personalized attention which constitute the primary interpersonal encounter with their patients. professional dominance takes precedence in a process in which the patient is also offered input. However. Doctors have superior knowledge in their field of practice – after all. and is therefore symmetrical. humanizing it. In addition. doctor and nurse complete their individual identity. and a sense that the parties are autonomous agents capable of pledging and fulfilling pledges’ (Veatch. We all generally value our autonomy. In the guidance-cooperative model. and that health care demands full attention to both domains. Patients enter into a relation with health care professionals not as equals. realistically and appropriately. want the doctor to take responsibility for their health’ (Tauber. and providing self-fulfillment to those involved in it. but argues that there is no equality or parity between the roles of the healer and the ill. By assuming responsibility for care. but still ‘most patients. the ‘awesome responsibility’ of being a doctor is not something external or imposed to their professional identity.2008. In turn this makes it possible to reintroduce responsibility into medicine. In other words. Tauber agrees that the physician’s expertise grants no moral superiority. see Tauber.Back to Basics in Bioethics 7 covenant medical ethics (also known as the ‘contract model’) relies on notions such as ‘moral equality between the partners. Patient Autonomy 62–3). the care provided by nurses is more intimate. In contrast with that of doctors. This way of looking at the health care relationship stresses the features that both patients and physicians might equally have. Tauber does not want to substitute science with morals – rather.00190. © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. Patient-Physician Relation 3.
not a starting point in health care ethics. R. After all. and this sense must emanate from compassion. Relational autonomy is a result. Physician responsibility. Patient Autonomy 201). the health care relationship is already given. Second. all health care professionals are defined by this responsibility (74. and it is intrinsically deliberative: it does not expect or deserve automatic respect for its demands. even pre-reflective.1111/j. Thus his notion of selfhood and autonomy allows for a balance of rights and responsibilities consistent with the deeper moral agenda of an ethics of care. it must take into account other moral principles. often represents the exercise of autonomy’ (Tauber. let us now remember the three basic precepts of Tauber’s ethics of responsibility (Confessions of a Medicine Man 112–17). However. It is the only means for individuals to be authentically autonomous: in Tauber’s way of understanding the self as a ‘confluence of relationships and social obligations that are constitutive of identity’. the relationship between self and other is radically nonsymmetrical. Potter’s original coinage of the term ‘bioethics’ in 1970 referred to a bridge between science and the humanities. his position is quite in tune with the historical origins of bioethics.8 Back to Basics in Bioethics In general. Das Prinzip Verantwortung – the principle or ‘imperative’ of responsibility – Jonas attempts to consider the global © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10.00190. not a bioethicist – at least not in the restricted sense that identifies it as a subfield of ethics applied to medicine. and sometimes give way to them. In the following section. The Principle of Responsible Autonomy Jonas is considered as a philosopher of biology and of technology.2008. with its more general concerns about the consequences of new technologies on human life. it is by means of deliberation. First. that persons assume responsibility for their choices and actions and thereby enact their autonomy: ‘The act of reflection.1747-9991. as one of responsibility. patient responsibility does not need to be this automatic. Third. is thus construed as primary. on the contrary. wherein the patient abdicates a portion of her autonomy.x . Tauber claims that in the medical scenario the other is ‘given’ as the object of care (105). In one of his main works. 117). health care ethics must acknowledge the primacy of trust. ‘designed to guide human survival’ (Whitehouse). To summarize. the quest for self-knowledge that will balance rational and emotional forces. as the answer elicited by the object of care. in a health care context. respect for autonomy may legitimately be subordinated to other moral principles that determine how the self is governed within a social context (85). a priori. I will supplement and illustrate this position with that of Hans Jonas (1903–93) in order to provide a more comprehensive sketch of the ethics of responsibility. V. as ‘a global integration of biology and values’. Rather. by the weighing of alternatives. 6. On the other hand.
that is. it is linked with basic notions in civil and criminal law such as compensation or penalty. the caused damage or other consequences of the action. responsibility appears in two senses: first. the ‘for’ of being responsible is obviously distinct from that in the purely self-related [formal] sense.00190. The shrinking of responsibility found by Tauber in the social and cultural movements associated with the birth and development of bioethics could be understood as a replacement of substantive with formal responsibility. This kind of responsibility is ‘basically one-sided’ (39). whatever they are. On the other hand. writes Jonas. He then argues that the enlargements of human power through technology carry with them expansions of human moral responsibility. someone who honors his or her professional responsibilities (90). in need of it or threatened by it. that such acting is under the agent’s control. Relational autonomy brings about substantive responsibility. We speak then of two different things when we say that a physician is responsible for what happened to a given patient and that a given person is a responsible physician. (92) Here lies a first point of contact with our previous discussion. that acting makes an impact on the world). Under these necessary conditions. and that the agent can foresee its consequences to some extent. Jonas’s characterization of substantive responsibility could provide elements for a better understanding of relational autonomy. responsibility for particular objects that commits an agent to particular deeds concerning them. Formal responsibility concerns actions of the past.2008.1111/j. For him. The ‘what for’ lies outside me. and with reaching it also a definite termination in time: ‘Parental responsibility has maturity for its goal and © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10.x .Back to Basics in Bioethics 9 condition of human life after modern technology has introduced possibilities to act of such novel scale that traditional ethics can no longer provide a basic framework of principles (Imperative of Responsibility 6–8). that is. which again is another point of contact with physician responsibility. toward the things to be done and the object of responsibility: Here. has a ‘definite substantive goal’: the autonomy of the individual. Child-rearing. but in the effective range of my power. even if they were not intentioned or foreseeable.1747-9991. the archetype of substantive responsibility is that of parents for their children: it is in this relationship to dependent progeny that Jonas finds the origin of the idea of responsibility in general. This archetype provides another interesting analogy between the parental and the health care relationship. and second. Jonas calls the first ‘formal responsibility’. This basic thesis is grounded on three ‘general conditions of responsibility’: causal power (that is. responsibility as being accountable for one’s deeds. substantive responsibility tends toward the future. while individualistic autonomy favors the formal sense of the word. which essentially includes a capacity for responsibility. and the second ‘substantive responsibility’. asymmetrical. If this is correct.
Thus the object of responsibility is submitted to the subject.x . and somewhat secondary to the substantive one: Evidently. but the actions of the subject are controlled by the needs of the object. since it is implanted in the very professional identity of the health care professionals. it is natural. ‘the essence of responsibility’ (96). On the other hand. in the same way. if less defined. This is also echoed in Tauber’s ethics of responsibility (Patient Autonomy 123). in parental relationships.00190. and what is more. The ‘ought-to-be’ of the object calls the subject to responsible and caring action. but from the rights and needs of the object of responsibility as we perceive them. according to Jonas.2008. According to Jonas. This is to say. that who ‘has acted for the good of those over whom he had power. the natural is the stronger. The same could be said of the responsible physician: that the paternalistic power over patients becomes a responsibility to care for them sums up. He finds another example of responsibility in the ‘real statesman’. This sentiment does not originate from the idea of responsibility.1747-9991.1111/j. the sentiment of responsibility. the principle of responsibility requires no deduction from a previous or more general principle. in moral (as distinct from legal) status. Finally. that physician responsibility has the patients’ health for its goal and terminates with it. (95) This naturalness of substantive responsibility entails that. It could be said. Conclusion This review of the most recent literature concerning the relationship of autonomy and responsibility in the clinical context found only one study © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. ‘because it is powerfully implanted in us by nature or at least in the childbearing part of humanity’ (39). 7. formal responsibility is mostly a contractual relationship of equal partners. This use of the parental archetype might lead us to think that Jonas’s and Tauber’s ethics of responsibility are intrinsically paternalistic. which in ideal cases is complemented by a subjective emotional commitment. Jonas interprets substantive responsibility as a nonreciprocal relation in which the agent’s power ‘is there to begin with’. if there were no responsibility ‘by nature’ there could be none ‘by contract’. for whom he had it’. but that is not the only comparison Jonas uses to describe this concept. Paraphrasing Jonas. The analogy with child-rearing certainly suggests so. in which response to need guides the physician’s actions. the power of the acting agent (or ‘subject’) over the object gives an objective meaning to responsibility. it is the original from which any other responsibility ultimately derives its more or less contingent validity. that is. sort of responsibility.10 Back to Basics in Bioethics terminates with it’ (108). it could be said the same about the health care relationship: the principle of responsibility is not reducible to a more general principle.
the biopsychosocial approach has been widely adopted by primary care providers. biopsychosocial approach to health and disease. the moral – because the organism is an integrated. irrespective of all the other contending personas.00190. and therefore not value-laden. doctors and managers should engage more directly with nurses and other health professionals when responding to reform initiatives.x . construed in a process of evaluations over time which inextricably combines facts and values. Even though a fact-driven clinical science has prevailed as medicine’s dominant ethos. But this allegedly value-free concept of health. A crucial feature of the Tauber-Jonas model for an ethics of responsibility is that it does not rely on the fact/value dichotomy. functioning whole. and therefore medicine should be holistic in orientation. Health care needs are complex concepts. in their everyday practice. is formed in response to the physician’s obligation to the patient. This blurring of the fact/value distinction might be associated with a holistic. George Khushf (20) argues. those facts are biological function statements susceptible to descriptive analysis. of professional integrity. the aspiration to rigidly separate the factual and the evaluative collapses when physicians begin to view patients not as collections of diseases or organs but first and foremost as people in need. this article proposes that only by re-establishing ‘responsible autonomy’ as the primary organizing principle of clinical work can patients and professionals strike a balance between the conflicting ethical demands of health care. In a broad sense these choices are ordered by ethics – the ethics of care. © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10.) explicitly arguing that. and medicine as an intrinsically moral activity. to break their destructive antagonism over issues of health service modernization. The reason for the prevalence of the factual paradigm. Tauber recognizes as a fact that physicians are constantly making value judgments – ranging from interpretations of data. (Patient Autonomy 175) In the health care relationship.1747-9991. from ‘values’. to forming relationships with patients and hospital personnel. Quite on the contrary. ‘facts’ are not previous to or independent from ethics. As a result. And underlying each of these ethical structures is an ‘ethics of responsibility’. is that modern medicine involves a ‘thought style’ that presupposes at multiple levels the fact/value dichotomy. Enlarging its argument. This approach attempts to address elements of personhood that have no firm and delineated objective basis – the social. the emotional.1111/j. upon which decisions concerning values are to be subsequently made.2008. and drawing upon the already described Tauber-Jonas model. most doctors think that they deal primarily with clinical facts.Back to Basics in Bioethics 11 (Degeling et al. to choosing a clinical strategy. of personal belief. in which clinical science has no underlying moral agenda. makes it impossible to properly understand central concepts in health care such as that of ‘need’. By this I mean that physician identity.
L. Degeling. Jr.1747-9991. Cambridge Quarterly of Healthcare Ethics 16 (2007): 415–19.. H. Maxwell. The Imperative of Responsibility. ‘The Triumph of Autonomy in Bioethics and Commercialism in American Healthcare’. O. © 2008 The Author Journal Compilation © 2008 Blackwell Publishing Ltd Philosophy Compass 4 (2009): 10. New York. and J. Engelhardt. ‘Medical Ethics’ Appropriation of Moral Philosophy: The Case of the Sympathetic and the Unsympathetic Physician’. and B. Jonas. Medicine. His main interests are in healthcare. J. Gipuzkoa. and a member of the Ethics Committee in this city’s hospital. Cambridge Law Journal 65 (2006): 397–422. Health Care and Philosophy 10 (2007): 19–27. Autonomy and Trust in Bioethics. T. Chicago. and L. is a Research Fellow at the Department of Philosophy of Values. with special emphasis on the role of the patients and lay participants in the healthcare relationship. Kennedy Institute of Ethics Journal 17.x .. Moreno. F. G. Coyle.. 70. J. Imber. H. commentaries and articles on these topics in journals such as Bioethics and The American Journal of Bioethics. B. University of the Basque Country at San Sebastian (Spain). 2008)). P. British Medical Journal 326 (2003): 649–52.00190.. R. ‘Medicine. Note * Correspondence address: Tolosa etorbidea.1111/j.1 (2007): 3–22. B. 20018 San Sebastian. R. He has published reviews. Email: antonio.12 Back to Basics in Bioethics Acknowledgments The author would like to thank a Philosophy Compass reviewer for helpful comments and suggestions. Journal of Medical Ethics 29 (2003): 307–12. IL/London: The U of Chicago P. NJ: Princeton UP. and environmental ethics. McCullough. This work was written during a stage at the Boston University Center for Philosophy and History of Science.casado@ehu. and Modernisation: A “Danse Macabre”?’. Khushf.D. Gillon. Ph. ‘An Agenda for Future Debate on Concepts of Health and Disease’. research. Management. 1984. Brazier. and supported by the Spanish Government by means of research project FFI2008-06348-C02-02/FISO. ‘Ethics Needs Principles – Four Can Encompass the Rest – and Respect for Autonomy Should Be “First among Equals” ’. Childress. Trusting Doctors: The Decline of Moral Authority in American Medicine. NY: Oxford UP. Cambridge: Cambridge UP. and F. 2008. Short Biography Antonio Casado da Rocha. J. Garrett. ‘Bioethics and the Philosophy of Medicine: A Thirty-Year Perspective’. Kennedy. In Search of an Ethics for the Technological Age.es. and has authored a book length introduction to medical ethics in Spanish (Bioética para legos (Madrid/México: Plaza & Valdés. Journal of Medicine and Philosophy 31 (2006): 565–8. Works Cited Baker. 2002. Jotterand. M. R. Beauchamp. 2008. J.2008. Spain. Principles of Biomedical Ethics. Princeton. ‘Do No Harm: Do Patients Have Responsibilities Too?’. S. 6th ed. O’Neill. T.
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