Book review: -
Practicing Medicine and Ethics: Integrating Wisom, Conscience, and Goals of Care, Lauris Christopher Kaldjian.  New York, NY: Cambridge University Press, 2014. ISBN 978-110701216

Best, Megan

English

ResearchOnline@ND (University of Notre Dame)

The University of Notre Dame Australia ResearchOnline@ND Philosophy Papers and Journal Articles School of Philosophy 2017 Book Reviews: Practicing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of Care Megan Best The University of Notre Dame Australia, megan.best@nd.edu.au Follow this and additional works at: https://researchonline.nd.edu.au/phil_article  Part of the Philosophy Commons  This book review in a scholarly journal was originally published as: Best, M. (2017). Book Reviews: Practicing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of Care. Ethics and Medicine, 33 (2), 121-122. Original book review in a scholarly journal available here: https://www.ethicsandmedicine.com/2017/05/ethics-medicine-volume-332-summer-2017/ This book review in a scholarly journal is posted on ResearchOnline@ND at https://researchonline.nd.edu.au/phil_article/56. For more information, please contact researchonline@nd.edu.au. Vol. 33:2 Summer 2017121Book ReviewsPracticing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of CareLauris Christopher Kaldjian. New York, NY: Cambridge University Press, 2014. I S B N  9 7 8 - 11 0 7 0 1 2 1 6 5 .  2 7 6  PA G E S ,  C L O T H ,  $ 1 0 3 . 0 0 .How refreshing to encounter a book on medical ethics which begins by proclaiming the need for physicians to have wisdom and integrity. Here we have an author who takes seriously the impossibility of separating medical practice from one’s deeply held convictions. This book is an academic study of the place of individual beliefs of the physician in shared decision making with patients. The author is trained in medicine as well as ethics and, as such, is admirably equipped to tackle the issues raised at the interface of clinical medicine and ethical decision making. In this book he aims to locate these topics within a framework of practical wisdom.The first section of the book sets the scene. The author’s arguments are based on the premise that medicine is an innately moral practice, the moral value and physical embodiment of human beings making ethics and science inseparable as the physician takes on the role of healer. Furthermore, the patient’s value as a person obligates the physician to act in the best interests of the patient within a relationship of trust. Healthcare practitioners are challenged as they seek to reconcile their own personal beliefs with professional medical ethics. At the same time they face potential ethical conflicts with their patients, and all this needs to be done without relinquishing their role as patient advocate. Clinicians will be familiar with the need to develop goals of care for individual patients before it is possible to determine how such outcomes will be achieved. Virtue ethics with its “telos” (end or goal) of action is presented as an appropriate model for ethical decision making. The author suggests that healthcare professionals require the virtue of practical wisdom in order to balance diverse factors such as patient beliefs, therapeutic burdens and benefits, and financial costs in the task of pursuing the internal goods of medicine. The current tendency to focus on the means of medicine (such as tests and treatments) to frame decision making is criticized as decisions may end up reflecting what is available or convenient rather than what the patient values. Furthermore such an approach renders the physician a technician rather than a trusted advisor. By adopting practical wisdom, teleological thinking can be navigated in a pluralistic culture, and doctors can fulfill their socially appointed role without compromising their or their patient’s moral integrity.The author then spends time examining how conscience has been understood throughout history. This concept is examined regarding its relation to reason, its fallibility and its authority, and the individual responsibility to form and inform one’s conscience. Conscience is seen as a way of understanding what matters most in the moral life and is equated with the idea of integrity, or “integration” of one’s values, actions, and identity. The primacy of physician integrity is emphasized. Conscience is considered within the utilitarian matrix of modern medicine and criticisms of conscientious objection for being “self-indulgent” are challenged. This leads to a discussion of the interplay of personal ethics with professional practice, examining some current professional statements on conscientious objection to illustrate problems which have resulted from trying to separate conscience into personal and professional parts. The third section reiterates the importance of moral integrity for healthcare professionals in a pluralistic culture. Kaldjian argues that in our practice of medicine we are all influenced by our foundational beliefs, whether religious or philosophical, and that there is no meaningful distinction between the two. This is because all moral frameworks have Ethics & Medicine122the same function, that is, to help the individual determine what is real and what is good. However, in a morally pluralistic setting it is not clear to what extent physicians may act on foundational beliefs within their professional practice and the place of religious beliefs in influencing public policy is debated.Physician unwillingness to provide a service requested by a patient is often framed as an example of a doctor imposing their beliefs on the patient, and thereby violating patient autonomy. An alternative view is offered—that it may be an opportunity for bilateral respect for moral agency between doctor and patient. The positive work of conscience is also noted, by which conscientious physicians are compelled to actions that complement beliefs, even if it involves self-sacrifice, in ways that sustain the traditional ends of medicine such as comforting the sick. Those opposing conscientious objection often invoke the principle of patient autonomy as an overriding ethical principle, but by considering topical ethical debates, Kaldjian shows that, in fact, it is not only conscience that is being judged in these situations. While in contentious issues such as abortion, patient autonomy is regularly valued above protection of conscience. In other scenarios, such as patient requests for futile care, patient autonomy is routinely overruled. In the latter situation, this is often done on the grounds that futility judgments involve medical, not moral evaluation. However, as argued above, the medical and the ethical cannot be separated and such claims are questionable. In short, Kaldjian sees moral integrity as a core requirement for healthcare professionals, when integrity and conscience are understood as meaning consistency between what one believes and what one does. Therefore he suggests that discussions about conscience need to be separated from assessments of specific clinical contexts, and conscience seen for what it really is—“the final and best assessment of what (the physician) believes is right, even if that assessment may in fact be wrong” (108).The myth of secular neutrality is rejected, and a critique of why we need to take personal convictions of healthcare practitioners seriously is welcome in a community discussion which at times loses sight of the dangers of trying to separate a professional from their most deeply held views and the benefits of having healthcare professionals of integrity. Kaldjian points out that a world without diversity of opinion is one in which constructive critique of medical practice will be stifled to the disadvantage of all. This is a timely contribution in view of debates regarding the place of conscientious objection in medicine and the challenges of moral pluralism. Instead of a tired recitation of principles, this account explores alternative ethical theories within which to approach shared decision making and grapples with the non-commensurability of medical outcomes between which clinicians are expected to choose. It reinforces the need to encourage conscience in healthcare in order to remind ourselves that clinical decision making is, and ought to be, a moral process by which patients, in all their complexity, are able to define their personal life goals and work towards them.The book is constructed in such a way that each chapter examines a component of the framework which is described in the final chapter. It is conveniently provided with summaries at the end of the first nine chapters, which allow the reader to proceed quickly through the book if desired. It is an excellent volume that will be of interest not only to medical practitioners, but also to those involved across the provision of healthcare—administrators and policy-makers, as well as educators in ethics and philosophy of medicine. Readers will gain increased insight into the need to integrate one’s beliefs into all areas of life and how to achieve this while learning how to argue for its necessity in the public square.Reviewed by Megan Best, PhD, MD, who is a post-doctoral Research Fellow in psycho-oncology and ethics at the University of Sydney, and Research Associate at the Institute for Ethics & Society at The University of Notre Dame, Australia.

Book Reviews: Practicing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of Care

https://researchonline.nd.edu.au/cgi/viewcontent.cgi?article=1056&amp;context=phil_article

Book Reviews: Practicing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of Care

Abstract

Similar works

Full text

Available Versions

ResearchOnline@ND (University of Notre Dame)