Barry, Robert

English

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The Linacre QuarterlyVolume 53 | Number 2 Article 135-1-1986[Book Review of ] Medical Ethics: The MoralResponsibilities of Physicians, by Tom L. Beauchampand Laurence B. McCulloughRobert BarryFollow this and additional works at: http://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationBarry, Robert (1986) "[Book Review of] Medical Ethics: The Moral Responsibilities of Physicians, by Tom L. Beauchamp and LaurenceB. McCullough," The Linacre Quarterly: Vol. 53 : No. 2 , Article 13.Available at: http://epublications.marquette.edu/lnq/vol53/iss2/13BOOK REVIEWS MEDICAL ETHICS: The Moral Responsibilities oj Physicians by Tom L. Beauchamp and Laurence B. McCullough New York: Prent ice-Hall, 1984. 172 pp., paper. $13.95. This book attempts to analyze many contemporary problems in medical eth ics according to the norms estab li shed by the principles of beneficence and autonomy. The a uthors contend that neither beneficence nor autonomy is sufficient to determine the ethically correct courses of action in va rious instances , and they a rgue in behalf of the dominance of the principle of beneficence limited by the principle of autonomy. Autonomy and beneficence are primafacie principles which can be overridden by other moral principles. but ordinarily cons iderations of utilit y or good consequences justify overriding these principles . They argue that the principle of beneficence must be weighed against various goods and harms caused by medical intervent ions , and this reduces to a uti litarian or consequentiali st reduction of the moral principles. The fundamental problem with this book is that the notions of beneficence and autonomy are made to carry too much freight, and more principles are needed. The authors admit that the autonomy-based model has crept into American medicine since 1972 and they appear to be uncomfortable with this development. The autonomy-based model is a clear rejection of the convenant-based mod el espoused by Paul Ramsey, and the autonomy model in practice tends to eliminate the duties and~bligations to care for and treat patients. If pure contentless patient autonomy is the model for decision-making. the phys ician has no rights before the patient. The "therapeutic privilege" may be invo ked . but how it wou ld fare is not at all clear. Another fundamental problem with this theory of ethics is that medical-ethical problems are becoming more and more complicated and , des pite this fact. their theory is excess ively simplistic and formal. There is no material content give n to either the principles of beneficence or of autonomy. and the authors refuse to articulate any " middle principles" which would give material content to these principles. The result is that their application is highly co lo red by social and cultura l biases. In an age of increasing et hical co mplexity, this trend to make et hical theory purely formal and abstract should be inhibited rather than promoted. This book traces the hi story of these two principles and aims at determining what courses of action are ethica lly appropriate in various so rt s of "hard cases". The foundation for the beneficence model in the Hippocratic Oath is mentioned. but the force of the Oath is discounted by an assertion that it was an Oath adopted by a small religious sect a nd that the Oath was in conflict wit h itself because doing good so metimes required doing harm. The authors complete ly ignore the medieval and high scholastic periods of ethics and moral theo logy where fundamental and derived moral principles were given clear and specific May, 1986 83 material content. The authors do not trace how the principle of autonomy was limited by the requirements of justice through the medieval legal and ethical period. The authors also try to determine when paternalistic actions may be justified. when autonomy can be limited by beneficence. Paternalism is defined as the intentional limitation of the autonomy of the patient in order to promote beneficence. They try to make these determinations by studying a hard case where a young man wanted to die rather than undergo painful and disfiguring burn treatments. He clearly wanted to die and control his own fate, but this was not to be permitted. Their study of this issue was hampered, however, because they failed to develop a theory which differentiates mandated treatments and electable care. Their theories of paternalism, autonomy and beneficence cannot generate these specific, concrete and practical principles and this calls into question all of their analyses. This book seems to have a preoccupation with rational suicide, and this concern seems to motivate the authors' study of paternalistic action. According to their principles, it is not clear how a paternalistic physician would be able to intervene to prohibit clear suicidal attempts by competent terminally ill patients. The authors object that permitting this would result only from a wooden reading of the principle of autonomy, but the principles of beneficence and paternalism are so formal and abstract that it is not clear why this reading would not be legitimate. Most argue for a limited paternalism policy. but it is difficult to determine the boundaries of this sort of policy. The authors distinguish between strong and weak paternalism and argue that weak paternalism collapses into the pure autonomy model. Weak paternalism holds that autonomy can be limited only if a patient is substantially non-autonomous, while strong paternalism holds that intervention can occur only when actions affect just the person himself. Both of these have their problems, as weak paternalism would probably permit a frightened stroke victim to go without protection, while strong paternalism would probably force useless and costly treatments on some patients. The authors need a theory of extraordinary medical treatments to explain why paternalism is justified in certain instances. They reduce the problem of paternalism to problems of autonomy and beneficence and call for a more comprehensive theory, but are unable to come to a clear and satisfactory resolution to their problems due to the abstractness of the fundamental principles they invoke. The authors attempt to resolve problems of treating patients with diminished competency and reduced autonomy, which is a serious problem because of their strong commitment to patient autonomy. They find it difficult to prohibit "rational suicide" because the principles requiring beneficence against clear and strongly autonomous decisions are very weak. Their judgments are hampered, howevq, by the lack of a theory of ordinary, required and mandatory medical treatments which cannot be withheld or rejected without violating justice. The authors seem uneasy with permitting rational suicide. but they cannot argue strongly against it because they do not believe that there are any medical treatments which must be provided and received. It would seem that suicide becomes a morally acceptable alternative in their theory because of the formal and abstract criteria they establish for reduced autonomy. If a patient can demonstrate that there are no external or internal constraints and show knowledge and understanding of a situation, then he or she could choose an action such as suicide by benign neglect. The language used to define external constraints is so vague, however, that it could never be clear if a person was free from them. The two writers develop conditions that limit autonomy. but they are not as precise as the traditional passion, fear, ignorance. Competence is ambiguously defined as the ability to perform a task. The criteria for competence are quite vague, such as the requirement that a rational reason for a choice be given. or the failure to give a risk ! benefit calculus. They recognize that labelinga person as incompetent can create all sorts of paternalistic events, but they hold that errors should be made on the beneficence side of the issue, even though it is difficult to decide what constitutes beneficence. To their credit. the authors recognize that determining or even defining competency is extremely difficult. Because of emotional factors or the inability of 84 Linacre Quarterly a patient to accept the reality of a co nditi o n, a co mpetent jud gment may be difficult. Beauchamp and McCullough recogn ize that rationality or ab ilit y to understand a situation does not mea n that a patien t can make a competent dec ision. The authors c hallenge the notion that the physician must a lways act in the best interes ts of the patient and they hold that third party interests ma y be pro moted at t he expe nse of the patient in so me cases. They would allow psychological a nd e moti o nal conseque nces of treatment to justify withholding beneficial trea tme nts from infan ts, for insta nce. But the reasons they give for upholding third-party inte rests are quite vague, abstract. form a l and difficult to apply in concrete circumstances. They ho ld tha t the pa ti ent' s interes ts only impose a primajacie dut y that can be overridden when so d o ing brings about a grea ter good. Determining when one can promote third part y interests is done by weighing va rious harms and benefits, which is essentiall y a co nseq uen tialist ana lys is. The funda mental problem with this met hod o logy is that one never knows what harms and benefit s are to be includ ed and one ne ve r knows when to stop sea rc hing for vlllues to be weighed. Whe n they urge that patient interests either be upheld or overridden, the authors invoke benefice nce, but they neve r sho w why there is a clear dut y to act bene fi cently as beneficence cou ld plausibly compel action in another direction. They invoke the " best interests" standa rd either to warrant or prohibit paternalist ic action, but they ne ve r give pers uasive reasons why this purely formal standard requires their reco mmended action. This book was quite dissatisfying because it relies so lely on abstract and formal principles. The authors almost seem fearful of esta bli s hing concrete, binding moral norms for medical practice, and one suspects that they want medical-ethical norms to be purely formal so that these norms ca n be used to permit or prohibit whatever they desire. There is no discuss ion of basic human goods or the virtues, which is ve ry peculiar for a work in medical ethics. They seem to assume that justice will be achieved by merely acting beneficentl y or by protecting autonomy, however they a re defined. The formalit y and abstractness of contemporary ethics should be a matter of concern, as we now see a campaign to legali ze euthanasia brea king upon our co untry. There is virtually no mention of the dut y to trea t patients, and only occasionally is there any mention made ofa "therapeutic privilege". They fail to consider the nature of medical treatme nts and the conditions of patients to show how those impinge upon the moral character of judgments. This book seems to be an endorsement of the pure and contentless patient autonomy model which all but obliterates ethical duties and obligations of hea lth care providers. If it is true that thi s model is gaining do minance in our country, then it might be necessary to take measures to protect the duti es and obligations of physicia ns to proVi de care and trea tment for medically vulnerable persons. -Rev, Robert Barry, ,O,P" Ph,D , National Endowment for the Humanities Fellow Washington , D ,C. I deal, Fact, and Medicine by Charles J. Dougherty Ne>!' York: Universill' of America Press. 1985. 202 pp. "It might be said by some tha t thi s whole work is far too relativistic, that it accepts too easily the claim that there are other significant moral alternatives, and that it therefore provides no absolute foundation for the choice of these idea ls and the associated ethical May, 1986 85 

[Book Review of] \u3cem\u3eMedical Ethics: The Moral Responsibilities of Physicians\u3c/em\u3e, by Tom L. Beauchamp and Laurence B. McCullough

https://epublications.marquette.edu/cgi/viewcontent.cgi?article=3585&amp;context=lnq

[Book Review of] \u3cem\u3eMedical Ethics: The Moral Responsibilities of Physicians\u3c/em\u3e, by Tom L. Beauchamp and Laurence B. McCullough

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