Stevenson University Medical Ethics Paper

Read the texts assigned for the appropriate module, then pick an idea or an argument you found interesting and reflect critically on it. You do not have to cover all the readings for that module (and please, do not merely summarize, but reflect critically on the readings!).

SECTION 1
AUTONOMY, PATERNALISM,
AND MEDICAL MODELS
HIPPOCRATIC OATH
I swear by Apollo the physician, and Asclepius, and
I will not give a lethal drug to anyone if I am
asked, nor will I advise such a plan; and similarly I
Hygieia and Panacea and all the gods and god­
desses as my witnesses, that, according to my abil­
will not give a woman a pessary to cause an abortion.
contract:
out my life and my art.
In purity and according to divine law will I carry
ity and judgment, I will keep this Oath and this
I will not use the knife, even upon those suffer­
To hold him who taught me this art equally dear
to me as my parents, to be a partner in life with him
ing from stones, but I will leave this to those who
and to fulfill his needs when required; to look upon
are trained in this craft.
,
his offspring as equals to my own siblings, and to
Into whatever homes I go, I will enter them for the
teach them this art, if they shall wish to learn it,
benefit of the sick, avoiding any voluntary act of
impropriety or corruption, including the seduction of
without fee or contract; and that by the set rules,
lectures, and every other mode of instruction, I will
women or men, whether they are free men or slaves.
impart a knowledge of the art to my own sons, and
Whatever I see or hear in the lives of my
those of my teachers, and to students bound by this
patients, whether in connection with my profes­
contract and having sworn this Oath to the law of
sional practice or not, which ought not to be spoken
of outside, I will keep secret, as considering all such
medicine, but to no others.
I will use those dietary regimens which will bene­
things to be private.
So long as I maintain this Oath faithfully and
fit my patients according to my greatest ability and
judgment, and I will do no harm or injustice to them.
without corruption, may it be granted to me to par­
take of life fully and the practice of my art, gaining
the respect of all men for all time. However, should
I transgress this Oath and violate it, may the oppo­
Translated by Michael North, National Library of Medi­
cine, 2002.
site be my fate.
59
60
Part One I Foundations ofthe Health Professional-Patient Relationship
THE REFUTATION OF MEDICAL PATERNALISM
Alan Goldman
In the case of doctors. fue question is whethel.’ they·
have the authority to make decisions for others that
they would lack as nonprofessionals. The goal of
providing optimal health treatment may he seen t o
oonflict in some d.rCUinStances With the otherwis.e
overriding duties to tell the patient the truth about
his condition ol’ to allow him to make decisions
vitally affecthlg.his. ownintetests. Again the assump­
tion of the profession itself appears to be that the
doctor’s role is strongly differentiated in this sense.
The Principles of Medical Ethics of the American
Medical Association leaves the question of informing
the patient of his own condition up to the pro­
fessional judgment of the physician, presumably in
relation to the objective of maintaining or improving
the health or well-being of the patient.1 I shall con­
centrate upon these issues of truth telling and
informed consent to treatment in the remainder of
this chapter. They exemplify our fundamental issue
because the initially obvious answer to the question
of who should make decisions or have access to
information vital to the interests of primarily one
person is that person himself.2
Rights ate reco�ed, we have said,, pm:tially to
permit individuals, control over their own fumes.
Regarding decisions vital to the interests of only
particular individuals, there are three main reasons
why such decisions should normally be left to the
individuals themselves, two want-regarding and
one ideal-regarding. First is the presumption of
their being the best judges of their own interests,,
which may depend upon personal value orderings
known only to them. There is often a temptation for
others to impose their own values and preferences,
but this would be less likely to produce satisfaction
for the individuals concerned. The second reason is
From The Moral Foundations of Professional Ethics by Alan
Goldman, Rowman and Littlefield, 1980. Reprinted by
permission of the publisher.
Editors’ note: Some text and author’s notes have been cut.
Students who want to read the article in its entirety should
consult the original.
the independent value of self-determination, at
least in regard to important decisions (in medical
contexts decisions may involve life and death altell­
natives, affect the completion of major life projects,
or affect bodily integrity). Persons desire the right
or freedom to make their own choices, and satisfac­
tion of this desire is important in itself. In addition,
maximal freedom for individuals to develop their
own projects, to make the pivotal choices that
define them and to act to realize them, allows for
the development of unique creative personalities,,
who become sources of new value in the goods they
creaJ;e and that they and others enjoy.
Resentment as well as overall harm is therefore
generally greater when caused by a wrong, even if
well-meaning, decision of another than when
caused to oneself. There is greater chance that the
other person will fail to realize op.e’s own values in
making the decision, and, when this happens, addi­
tional resentment that one was not permitted the
freedom to decide. Thus, since individuals normally
have rights to make decisions affecting the course of
their lives and their lives alone, doctors who claim
authority to make medical decisions for them that
fall into this self-regarding category are claiming
special authority. The no.rm.ally •existin,g right to
�d:etatD:J.inilti� implies sevaml m.01e sptiltltic
rights :in the medical cont�t. These include the
right .to be told thl:l troth about .on&s conditien, a!tla
the right to iwoept trr De.fuse or withdraw from treat­
ment on the basis of ad�qua:te �ti.on ragatd­
mg altamati’Vl!B, risks rutd ll:Ultertami:ies. H doctors
are permitted or required by the principle of pro­
viding optimal treatment, cure or health mainte­
nance for patients sometimes to withhold truth or
decide on their own what therapeutic measures to
employ, then the Hippocratic principle overrides
important rights to self-determination that would
otherwise obtain, and the practice of medicine is
strongly role differentiated.
This is clear enough in the case of informed con­
sent to therapy; it should }?e equally clear in the case
of withholding truth, from terminally ill patients for
Section 1 I
Autonomy,
Paternalism, and Medical Models
example. The right violated or overridden when
truth is withheld in medical contexts is not some
claim to the truth per se, but this same right to self­
determination, to control over decisions vital to the
course of one’s life. In fact, it seems on the face of it
that there is a continuum of medical issues in which
this right figures prominently. These range from the
question of consent to being used as a subject in an
experiment designed primarily to benefit others, to
consent to treatment intended as benefit to the
atient himself, to disclosure of information about
the patient’s condition. In the first case, that of med­
ical experimentation, if the consent of subjects is
required (as everyone these days admits it is), this is
p
6
important rights in contexts in which this is nece!
sary to prevent serious harm to the patient’s healtl
then his position appears to meet in a dramatic wa
our criteria for strong role differentiation.
THE CASE FOR MEDICAL
PATERN ALISM
Since the primary rights in potential conflict wit
the presumed fundamental norm of medical ethic
are rights of patients themselves, and since the norr
seeks to serve the health needs of patients them
selves, arguments in favor of strong role differentia
tion in this context are clearly paternalistic. We ma
harm
is stronger than
partly because the duty not to
define paternalism. as the overriding or restrictiqg. c:
any
the duty to provide benefl.ts. Hence if there is
rights or freedott\S o.f individuals for their owi
they
risk of harm at all to subjects,
cannot be used
good. It can be justified even for competent adults :iJ
without consent, even if potentiw banefi:ts to others
contexts in which they can be assumed to act othet
is great. But consent is required also because the
right to self-determination figures independently of
calculations of harms and benefits. Thus a person
nermally eught not to• be used without his consent
to benefit others even if he is not materially harmed.
This same right clearly opposes administration of
treatment to patients without their consent for their
own benefit. It opposes as well lying to patients
about their illnesses in order to save them distress.
What is at least prima £acie Wllong with lying in
such cases is that it shifts power to decide future
courses of action away from the person to whom the
lie is told.a A person who is misinformed about his
own physical condition may not complete certain
projects or perform certain actions that he would
choose to perform in full knowledge. If a person is
terminally ill and does not know it, for example, he
may fail to arrange his affairs, prepare himself for
death, or may miss opportunities to complete pro­
jects or seek certain experiences always put off
before. Being lied to can reduce or prevent from
coming into view options that would otherwise be
live. Hence it is analogous to the use of force, per­
haps more coercive than the use of force in that there
is not the same chance to resist when the barrier is
ignorance. The right to know the truth in this con­
text then derives from the right to make for oneself
important decisions relating primarily to one’s own
welfare and to the course of one’s life. If the doctor ‘s
authority is to be augmented beyond that of any
nonprofessional, allowing him to override these
wise against their own interests, values, or true preJ
erences. Individuals might act in such self-defeatin:
ways from ignorance of the consequences of thei
actions, from failure to weigh the probabilities o
various consequences correctly, or from irrationa
barriers to the operation of normal short-term moti
vations. Paternalistic measures may be invokec
when either the individual in question, or any ratio
nal person with adequate knowledge of the situa
tion, would choose a certain course of conduct, anc
yet this course is not taken by the individual solel:
because of ignorance, carelessness, fear, depression
or other uncontroversially irrational motives.4
Paradigm Cases
It will be useful in evaluating arguments for stroni
role differentiation for doctors to look first at criteri;
for justified paternalism in nonmedical cases, it
order to see then if they are met in the medical con
text. In approaching the controversial case of with
holding truth from patients, we may begin witl
simpler paradigm cases in whieh patamalisti1
pEWtliasible
behavi0r is unootd:rovElllSially
o
required. We can derive a rule rrom these cases fo
the justification of such conduct and then apply th1
rule to decide this fundamental question of medica
ethics.
The easiest cases to justify are those in which < person is acting against even his itnmediate desire: Part One I Foundations of the Health Professional-Patient Relationship 62 out of ignorance: Dick desires to take a train to New not), and that there is an important independent York, is about to board the train for Boston on the value to self-determination or individual freedom warn him he can only be grabbed and shoved in sons value freedom and because such freedom is other side of the platform, and, without time to , and control (the latter being true both because per­ the other direction. Coercing him in this way is necessary to the development of genuinely individ­ movement for his own good. "His own good" is justifying paternalism in more controversial cases paternalistic, since it overrides his right of free ual persons). The additional criteria necessary for uncontroversial in interpretation in this easiest case. relate to the potential harm to the person from the and long-range preferences (the two are not in con­ severe, and irreversible (relative to the degree of which persons voluntarily act in ways inconsistent with their long-range preferences: Jane does not because the action coerced is only a minor nuisance It is defined by his own clearly stated immediate flict here). Somewhat more difficult are cases in desire to be seriously injured or to increase greatly her chances of serious injury for trivial reasons; yet, out of carelessness, or just because she considers it a action in question: it must be relatively certain, coercion contemplated). These further criteria are satisfied as well in the case of motorcycle helmets, in comparison to the severity of potential harm and the degree of risk. It is important for the course of the latter argu­ nuisance and fails to apply statistical probabilities ment to point out that these additional criteria relat­ while her action is voluntary in relation to trivial opposition between allowing freedom of action and to her own case, she does not wear a helmet wilen riding. a motorcrele. Here it might be claimed that, short-term desires, it is nevertheless not fully vol­ untary in a deeper sense. But to make this claim we must be certain of the person's long-range prefer­ ences, of the fact that her action is inconsistent with these preferences (or else uncontroversially incon­ ing to the harm that may result from self-regarding actions need not be viewed in terms of a simple preventing harm. It is not simply that we can over­ ride a person's autonomy when in our opinion the potential harm to him from allowing autonomous decision outweighs the value of his freedom. His right to self-determination, fundamental to individ­ sistent with the preferences of any rational person). uality itself, bars such offsetting calculations. The be grateful in the long run for the additional coer­ cive motivation. In this example we may assume evidence that the person is not acting in accord with his own values and preferences, that he is not acting wearing a helmet is not an essential feature in the moral theory of the type I am assuming as the We must predict that the person herself is likely to these criteria to be met. For rational people, not magnitude of harm is rather to be conceived as autonomously in the deepest sense. A rights-based enjoyment of riding a motorcycle, even if people framework for this study will view the autonomy of the transportation. The chances are far greater that ular goods he enjoys or harms he may suffer. The ride them primarily for the thrill rather than for a rider will at some time fall or be knocked off the cycle and be thankful for having a helmet than that the individual as more fundamental than the partic­ autonomous individual is the source of value for those other goods he enjoys and so not to be sacri­ one will prefer serious head injury to the inconve­ ficed for the sake of them. .The point here is that injury. Therefore we may justifiably assume that a agent's immediate or short-term preferences are her own true long-range values and preferences. order of priority. nience of wearing protection that can prevent such person not wearing a helmet is not acting in light of As the claim that the individual's action is not truly voluntary or consistent with his preferences or values becomes more controversial, additional criteria for justified paternalism must come into play. They become necessary to outweigh the two cases of justified paternalism, even where the overridden, need not be viewed as reversing that . Criteria for justified paternalism are also clearly satisfied in certain medical contexts, to return to the immediate issue at hand. State control over physi­ cian licensing and the requirement that pi:escdp­ considerations mentioned earlier: the presumption tions be obtamed for many kinds of drugs are medical cases ift point. Licensing physicians pre­ (that interference will be more often mistaken than also limits these persons' freedom of choice for their that individuals know their own preferences best vents some quacks from harming other persons, but Section 1 I Autonomy, Paternalism, and Medical Models own good. Hence it is paternalistic. We may assume that no rational person would want to be treated by a quack or to take drugs that are merely harmful, but that many people would do so in the absence of controls out of ignorance or irrational hopes or fears. While controls impose costs and bother upon people that may be considerable in the case of hav­ ing to see a doctor to obtain medication, these are relatively minimal in comparison to the certainty, severity and irreversibility of the harm that would result from drugs chosen by laymen without med� ical assistance. Such con:trols are therefore justified, despite the fact that in some cases persons might benefit from seeing those who could not obtain licenses or from choosing drugs themselves. We can assume that without controls mistakes would be made more often than not, that serious harm would almost certainly result, and that people really desire to avoid such harm even given additional costs. There is another sense too in which paternalistic measures here should not be viewed as prevention of exclusively self-regarding harm by restriction of truly autonomous actions. The harm against which laymen are to be protected in these cases, while deriving partly from their own actions in choosing physicians or drugs, can be seen also as imposed by others in the absence of controls. It results from the deception practiced by unqualified physicians and unscrupulous drug manufacturers. Hence controls, rather than interfering with autonomous choice by laymen, help to prevent deceptive acts of others that block truly free choice.5 This is not to say that some drugs now requiring prescriptions could not be safely sold over the counter at reduced cost, or that doctors have not abused their effective control over entrance to the profession by restraining sup­ ply in relation to demand, maintaining support for .exorbitant prices. Perhaps controls could be imposed in some other way than by licensing under professional supervision. This issue is beyond our scope here. The point for us is that some such restraints appear to be necessary. Whichever form they take, they will be paternalistic, justifiably so, in their relation to free patient choice. We have now defined criteria for justified pater­ nalism from considering certain relatively easy examples or paradigm cases. fhe prin'clpal C?rHer.ion is that an btdividtta1 hll acthtg agaimrt his own pl'e­ domina:rtt lon,g;-range value prefereJllces:. ·l'Y!' that a: . . 63 strong likelihood exiSt that he will so act if not pre­ vented: Where either clause is controversial, we judge their truth by the likelihood and seriousness of the harm to the person risked by his probable action. It must be the case that this harm would be judged clearly worse from the point of view of the person himself than not being able to do what we prevent him from doing by interfering. Only if the interference is in accord with the person's real desires in this way is it justified. Our question now is whether these criteria are met in the more contro­ versial medical cases we are considering, those of doctors' withholding truth or deciding upon courses of treatment on their own to prevent serious harm to the health of their patients. Application of the Criteria to Medical Practice The argument that the criteria for justified rp� . .. ism are 1satis£ied in these more cowoveeial m1:1.dical cases begins .&om the pmmdW that th1;1 dotitor is mom likely to know the OOut'S� of treatment optimal for h:n-provins :iw:erall health or pl!olonging. life ihan ia his paiient The patient will be comparatively ignorant of his present condition, alternative treat­ ments, and risks, even when the doctor makes a rea­ sonable .attempt to educate him on these matters .. More important, he is apt to be emotional and fear­ ful, inclined to hold out false hope for less painful treatments with little real chance of cure, or to despair of the chance for cure when that might still be real. In such situations ·it again could be claimed, as in the examples from the previous subsection, that patient choice in any event would not be truly voluntary. A person is likely to act according to his hue long-range values only when his decision is calm, unpressured, and informed or knowledgeable. A seriously ill person is unlikely to satisfy these con­ dltions for free choice. Choice unhindered by others ia nevertheless not truly free when determined by internal factors, among them fear, ignorance, or other irrational motivation, which result in choice at Wlriance with the individual's deeper preferences. In stich circumstances interference is not to be criti­ med 98 Jl8&tricti;ye ref fl'eerlt:!m. The semmd pimxiise ·states, 1!1m.t '.th:msa wm ctm.tt� s11lt dl'Jel:ors �aally d:esire· to b-.e � aTu.b\fa rd ahla1, 64 Part One I Foundations ofthe Health Professional-Patient Relationship Health and the prolonging of life may be assumed (according to this argument) to have priority among values for any rational persqn, since they are neces­ sary conditions for the realization of almost every other personal value. While such universally neces­ sary means ought to have priority in personal value orderings, persons may again fail to act on such orderings out. of despair or false hope, or simply lack of knowledge, all irrational barriers to gen­ uinely voluntary choice.When they fail to act ratio­ nally in medical contexts, the harm may well be serious, probable and irreversible. Hence another criterion for justified paternalism appears to be met; we have another sign that the probable outcome in these circumstances of unhindered choice is not truly desil:_ed,hence the choice not truly voluntary. While it is possible tha.f a doctor's prognosis might be mistaken, this can be argued to support further rather than weaken the argument for pater­ nalism;. For if the doctor is mistaken, this will infect the patient's decision-making process as well, since his appreciation of the situation can only fall short of that of his source of information. Furthermore, bad prognoses may tend to be self-fulfilling when revealed, even if their initial probability of realiza­ tion is slight. A positive psychological attitude on the part of the patient often enhances chances for cure even when they are slight; and a negative atti­ tude, which might be incurred from a mistaken prognosis or from fear of an outcome with other­ wise low probability, might increase that probabil­ ity.In any case it can be argued that a bad prognosis is more likely to depress the patient needlessly than to serve a positive medical purpose if revealed.The doctor will most likely be able to convince the patient to accept the treatment deemed best by the doctor even after all risks are revealed. The ability to so con­ vince might well be conceived as part of medical competence to provide optimal treatment. If the - doctor knows that he can do so in any case, why needlessly worry or depress the patient with dis­ cussion of risks that are remote, or at least more remote or less serious than those connected with alternative treatments? Their revelation is unlikely to affect the final decision, but far more likely to harm the patient. It therefore would appear cruel for the doctor not to assume responsibility for the decision or for remaining silent on certain of its determining factors. Thus all the criteria for justified paternalism might appear to be met in the more controversial cases as well. The analogies with our earlier exam­ ples appear to support overriding the patient's right to decide on the basis of the truth by the fundamen­ tal medical principle of providing optimal care and treatment.Let us apply this argument more specifi­ cally to ...the case of withholding truth when no other medical decisions remain to be made, when the question is what to tell the terminally ill patient for example. Here recognition of an absolute right of the patient is likely to result in needless mental suffering and even in some cases hasten death. The dying patient is likely to realize at a certain point that he is dying without having to be informed. If he does realize it, blunt and open discussion of the fact may nevertheless be depressing. What appear to be pointless deceptive games played out between patients and relatives in avoiding such discussion may actually express delicate defense mechanisms whose solace may be destroyed by the doctor's intrusion.When the doctor has no reason to predict such detrimental effects, then perhaps he ought to inform. But why do so when this is certain to cause needless additional suffering or harm? To do so appears not only wrong, but cruel. We certainly ar.e justified in lying to a person in order to prevent serious harm to another. If I must lie to someone in order to save the life of another whom the first person might kill if told the truth (even if the killing would be nonintentional), there is no doubt at all that I should tell the lie or with­ hold the information. Rights to be told the truth are not absolute, but, like all rights, must be ordered in relation to others. If I may lie to one person to save another from harm, why not then when the life of the person himself might be threatened or seriously worsened by the truth, as it might be in the medical contexts we are considering? Why should the fact that only one person is involved, that only the per­ son himself is likely to be harmed by the truth, alter the duty to deceive or withhold information in order to prevent the more serious harm? If it is replied that when only one person is involved, that person is likely to know the best course of action for himself, the answer is that in medical contexts this claim appears to be false. The doctor is likely to be better informed than the patient about his condition and the optimal treatments for it. Section 1 I Autonomy, Paternalism, and Medical Models 65 Thus there are two situations in which the doc­ The doctor ministers to his patient's needs, not to tor's duty not to harm his patient's health or shorten his immediate preferences. If this were not the case, his life might appear to override otherwise obtain­ doctors would be justified in prescribing whatever ing rights of the patients to the full truth. One is drugs their patients requested. That a person needs where the truth will cause direct harm-depression care suggests that, at least for the time being, he is or loss of continued will to live. The other is where not capable of being physically autonomous; and informing may be instrumentally harmful in leading given the close connection of physical with mental to the choice of the wrong treatment or none at all. state, the emotional stress that accompanies serious Given that information divulged to the patient may illness, it is natural to view the patient as relinquish­ be harmful or damaging to his health, may interfere ing autonomy over medical decisions to the expert with other aspects of optimal or successful treat- · for his own good. Being under a physician's care ment, it is natural to construe what the doctor tells entails a different relationship from that involved in the patient as an aspect of the treatment itself. As merely seeking another person's advice. such it would be subject to the same risk-benefit analysis as other aspects. Doctors must constantly THE REFUTATION OF MEDICAL PATERNALISM balance uncertain benefits and risks in trying to pro­ vide treatment that will maximize the probability of cure with least damaging side effects. Questions regarding optimal treatment are questions for med­ ical expertise. Since psychological harm must figure in the doctor's calculations if he is properly sensi­ tive, since it may contribute as well to physical dete­ rioration, and since what he says to a patient may cause such harm, it seems that the doctor must con­ strue what he says to a patient as on a par with what he does to him, assuming full responsibility for any harm that may result. Certainly many doctors do so conceive of questions of disclosure. A clear example of this assimilation to questions regarding treatment is the following: From the foregoing it should be self-evident that what is imparted to a patient about his illness should be planned with the same care and executed with the same skill that are demanded by any potentially thera­ peutic measure. Like the transfusion of blood, the dis­ pensing of certain information must be distinctly indicated, the amount given consonant with the needs of the recipient, and the type chosen with the view of avoiding untoward reactions.6 In order to refute an argument, we of course need to refute only one of its premises. The argument for medical paternalism, stripped to its barest outline, was: 1. Disclosure of information to the patient will sometimes increase the likelihood of depression and physical deterioration, or result in choice of medically inoptimal treatment. 2. Disclosure of information is therefore sometimes likely to be detrimental to the patient's health, perhaps even to hasten his death. 3. Health and prolonged life can be assumed to have priority among preferences for patients who place themselves under physicians' care.. 4. Worsening health or hastening death can there­ fore be assumed to be contrary to patients' own true value orderings. 5. Paternalism is therefore justified: doctors may sometimes override patients' prima fade rights to information about risks and treatments or about their own conditions in order to prevent harm to their health. When the patient places himself in the care of a physician, he expects the best and least harmful treatment, and the physician's fundamental duty, seemingly overriding all others in the medical con­ text, must be to provide such treatment. Indeed the terminology itself, "under a physician's care," sug­ gests acceptance of the paternalistic model of strong role differentiation. To care for someone is to pro­ vide first and foremost for that person's welfare.7 The Relativity of Values: Health and Life The ftcn.damentally fault"Y p.retttise m: tha tmgttment for paternalAstte role d1:££er en1i:aiill!l't for d:aet.ors is that whkh assuntes that ilil.lmlth or pliell\lnged life mttSt - a:bsolu.ta prlo:L'ity in the paiian-f:is IV'aiue C>:tde:l:’b.tp;s. In order for paternalistic interference to
be justi£iErd, a person must be acting irrationally or
66
Part One I Foundations of the Health Professional-Patient Relationship
inconsistently with his own long-range preferences.
The value ordering violated by the action to be pre­
vented must either be known to be that of the per­
son himself, as in the train example, or else be
uncontroversially that of any rational person, as in
others are not. Once more the quality and signifi­
cance of one’s life may take precedence over maxi­
mal longevity. Many people when they are sick
think of nothing above getting better; but this is not
true of all. A person with a heart condition may
the motorcycle helmet case.But �an we assumethat
decide that important unfinished work or projects
assumed to be always overriding for those who
Since people’s lives derive meaning and fulfillment
hea:iltb: artcl ptolonged life have top priority in any
rati.OJJa:l ordering? lf thE!se values could be safely
must take priority over increased risk to his health;
and his priority is not uncontroversially irrational.
seek medical assistance, then medical expertise
from their projects and accomplishments, a person’s
treatment, and decisions
well justify actions detrimental to his health ….
would become paramount in decisions regarding
on disclosure would
become assimilated to· those within the treatment
context.But in fact very few of us act according to
risking a shortened life for one more fulfilled might
To doctors in their roles as professionals whose
ultimate concern is the health or continued lives of
such an assumed value ordering. In designing
patients, it is natural to elevate these values to ulti­
toward minimizing loss of life, on the highways or
as it is in many cases, may appear as an ultimate
social policy we do not devote all funds or efforts
in hospitals for example.
mate prominence. The death of a patient, inevitable
defeat to the medical art, as something to be fought
If our primary goal were always to minimize
by any means, even after life has lost all value and
federal budget in health-related areas. Certainly
the previous section for assuming this value order­
fact grant to individuals rights to minimal risk in
necessary conditions for the realization of all other
risk to health and life, we should spend our entire
such a suggestion would be ludicrous.We do not in
meaning for the patient himself. The argument in
ing was that health, and certainly life, seem to be
their activities or to absolutely optimal health care.
goods or values.But this point, even if true, leaves
life of a certain quality with autonomy and dignity,
ultimate, or indeed any, intrinsic value, or whether
could never be justified.But when the quality of life
maintain that life itself is not of intrinsic value, since
From another perspective, if life itself, rather than
were of ultimate value, then even defensive wars
and the autonomy of an entire nation is threatened
from without, defensive war in which many lives
are risked and lost is a rational posture. To para­
phrase Camus, anything worth living for is worth
qying for. To realize or preserve those values that
give meaning to life is worth the risk of life itself.
Such fundamental values (and autonomy for indi­
viduals is certainly among them), necessary within
open the question of whether health and life are of
they are valuable merely as means.It is plausible to
surviving in an irreversible coma seems no better
than death.It therefore again appears that it is the
quality of life that counts, not simply being alive.
Although almost any quality might be preferable to
none, it is not irrational to trade off quantity for
quality, as in any other good.
Even life with physical health and consciousness
may not be of intrinsic value. Consciousness and
a framework in which life of a certain quality
health may not be sufficient in themselves to make
the value of mere biological existence.
ness are intrinsically good and others bad. Further­
becomes possible, appear to take precedence over
In personal life too we often engage in risky
activities for far less exalted reasons, in fact just for
the pleasure or convenience. We work too hard,
smoke, exercise too little or too much, eat what we
the life worth living, since some states of conscious­
more, if a person has nothing before him but pain
and depression, then the instrumental worth of
being alive may be reversed. And if prolonging
one’s life can be accomplished only at the expense·
know is bad for us, and continue to do all these
of incapacitation or ignorance, perhaps preventing
effects. To doctors in their roles as doctors ·an this
instrumental value of longer life again seems over­
things even when informed of their possibly fatal
may appear irrational, although they no more act
always to preserve their own health than do the rest
of us.If certain risks to life and health are irrational,
lifelong projects from being completed, then the
balanced.It is certainly true that normally life itself
is of utmost value as necessary for all else of value,
and that living longer usually enables one to complete
Section 1 I Autonomy, Paternalism, and Medical Models
67
more projects and plans, to satisfy more desires and
There is in addition another decisive consideration
derive more enjoyments. But this cannot be assumed
mentioned earlier, namely the independent value of
in the extreme circumstances of severe or terminal
self-determination or freedom of choice. Pe:ns.onal
illness. Ignorance of how long one has left may
autenomy over imponant ldefilsio:os in one’s1 life1 the
block realization of such values, as may treatment
with the best chance for cure, if it also risks incapac­
itation or immediate death.
Nor is avoidance of depression the most impor­
ability fo atteinpt to1 tealize1 one1s own va1tte at:del.”­
mg, is1 itldeed :SO :impartant thatrtOi’lnally E.0 itlll

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