DeGrazia, David

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Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=uajb20The American Journal of BioethicsISSN: 1526-5161 (Print) 1536-0075 (Online) Journal homepage: https://www.tandfonline.com/loi/uajb20Value Theory, Beneficence, and Medical Decision-MakingDavid DeGraziaTo cite this article: David DeGrazia (2020) Value Theory, Beneficence, and Medical Decision-Making, The American Journal of Bioethics, 20:3, 71-73, DOI: 10.1080/15265161.2020.1714806To link to this article:  https://doi.org/10.1080/15265161.2020.1714806Published online: 27 Feb 2020.Submit your article to this journal Article views: 185View related articles View Crossmark dataCiting articles: 1 View citing articles THE AMERICAN JOURNAL OF BIOETHICS2020, VOL. 20, NO. 3, 71–73https://doi.org/10.1080/15265161.2020.1714806OPEN PEER COMMENTARIESValue Theory, Beneficence, and Medical Decision-MakingDavid DeGraziaa,baNational Institutes of Health; bGeorge Washington UniversityJohan Bester’s target article (2020) explores conceptionsof well-being before proposing a hybrid objective-sub-jective approach in an effort to illuminate beneficence inmedicine. Bester is entirely correct that understandingthe nature of individual well-being—the study of whichphilosophers call prudential value theory (or value theoryfor short)—is central to in-depth understanding of ben-eficence, best interests, and related concepts (see alsoBrock 1993; DeGrazia 1995). Moreover, the vast majorityof specific ethical and prudential judgments his essayadvances are sensible. But I find the theoretical investiga-tion unsatisfactory. Because the thrust of his essay is the-oretical—engaging value theory as it pertains tomedicine—this commentary will focus on concernsabout his foray into value theory.Readers well-versed in the value theory literaturewill note that Bester engages little of it. He reliesheavily on an encyclopedia article about well-being(Crisp 2017), a very good article, but that is no substi-tute for being conversant with the primary literature.To be clear, I am not valorizing scholarship for thesake of scholarship. Rather, I believe that limitationsof the discussion are related to a superficial acquaint-ance with relevant literature and the issues and theor-etical options that it brings to life.For example, in characterizing general types ofvalue theory, he distinguishes subjective and objective-list theories but says little in describing the latter. Hedoes not identify any of the items that would appearon a plausible objective list (though later he mentionshealth and functioning, which are relevant to medi-cine). Instead, by way of summary, he states that onthis approach “interests are objective and not deter-mined by the individual” (54). The last five wordsmisleadingly overreach insofar as plausible objectivelists make some concessions to subjective accounts—in particular, treating self-determination and enjoy-ments as constituents of human well-being. (One ofthe few works in value theory Bester engages isPowers and Faden (2006). I find it odd that thismostly excellent work finds no place for enjoyments,satisfaction, or the like—no concession whatsoever tohedonism—in the objective list view it defends. Itdoes, however, include self-determination.)As the discussion proceeds in the section entitled“A Dilemma,” the question of what constitutes apatient’s well-being becomes conflated with the ques-tion of what constitutes the patient’s health. But valuetheory is not just about the nature of health, andpatients’ well-being is not reducible to their health.Bester asserts that the subjective conception of well-being (or health?) seems to prioritize respect for per-sons whereas the objective-list conception protectsequality of opportunity. But this seems muddled. Thenature of individual well-being is one thing, an issuein prudential value theory. Ethical principles areanother matter, an issue in ethical theory. Two peoplecould coherently agree on accounts of well-being anddisagree about ethical principles—or vice versa.Insufficient familiarity with theoretical options isapparent in the discussion of a case in which a patientasks a doctor to amputate an arm because it is “filledwith evil” and causes her severe distress. He stipulatesthat the patient is found to have decision-making cap-acity and “no delusion.” According to Bester, a sub-jective approach would judge that amputation wouldpromote the patient’s well-being.Bester is right to find this result counterintuitive butmistaken in eliciting this implication from a subjectiveapproach, assuming the latter is reasonably nuancedCONTACT David DeGrazia david.degrazia@nih.gov National Institutes of Health, Clinical Center (Bldg. 10), Bethesda, 20892 USA.This work was authored as part of the Contributor's official duties as an Employee of the United States Government and is therefore a work of the United States Government.In accordance with 17 USC. 105, no copyright protection is available for such works under US Law.THE AMERICAN JOURNAL OF BIOETHICS 71and plausible. First, to believe that one’s arm is filledwith evil is delusional. Appendages cannot be filledwith evil. Second, if the mere presence of a healthy,functioning arm is causing the patient distress, then apsychiatric problem is almost certainly what is drivingher preference, undercutting the stipulation that shehas decision-making capacity with respect to this par-ticular decision. Third, loss of the arm would entail asevere loss of functioning, pain and discomfort, andpossibly infections. Although it is conceivable that thelosses associated with the amputation would be out-weighed by whatever might be gained from removing abodily source of distress, this seems somewhat unlikely.What seems likely is that psychiatric treatment wouldbe more conducive than amputation to the patient’shealth and overall well-being.Bester also underestimates the ability of a subjectiveaccount to judge plausibly in the case of a patientwho insists on smoking. He suggests that physicianswho are adamant that smoking is bad for patients,even patients who maintain that smoking fits theirconception of a good life, are relying on an objectiveconception of well-being. Not necessarily. In assessingwhether something (e.g. smoking) is good for an indi-vidual, a plausible subjective account will factor in notonly whether an individual likes or prefers the activityor product, or finds it satisfying, but also how thatsomething will affect the individual, in terms of herown values and priorities, down the temporal road.20-year-old Sarah may enjoy smoking, may valuebeing contrarian, and may appreciate the opportunityto act contrary to prevailing middle-class norms ofsensible, healthful behavior. But Sarah will also surelydislike any downstream painful, debilitating effects ofsmoking such as shortness of breath and, if she isunlucky, lung cancer; and, unless she has money toburn and doesn’t care about charitable giving, itwould be rational for her to dislike the opportunitycosts associated with spending thousands of dollars oncigarettes. Now, if Sarah, despite her actual preferenceto smoke, would prefer to quit (assuming she couldmuster the will-power) if she understood the longer-term implications and took them fully into account,then a subjective value theory will judge that smokingis bad for her. In that rare case, however, where anindividual’s relevantly informed, autonomous prefer-ence would be to smoke, then a subjective view wouldjudge that smoking is not bad for her all things con-sidered (even if it is bad for her health). These cases, Iassume, are very rare or nonexistent.One more concern about the author’s foray intovalue theory. The section entitled “A ProposedSolution: A Hybrid Conception of Wellbeing forMedical Practice” appears to feature a conflationbetween two issues: (1) “What are the ultimate constitu-ents of an individual’s well-being?” and (2) “What gen-eral conditions reliably promote well-being?” The firstquestion is what divides value theorists and is presum-ably the issue the paper had been discussing in earliersections. Yet, notwithstanding the section title, the pro-posal Bester offers is not a solution to that issue becauseit features a discussion of all-purpose means—condi-tions that anyone could value as means to their ends,whatever they might be—the topic of the second ques-tion. Accordingly, the “solution” instructs clinicians toattend to such factors as patients’ freedom from painand suffering, prolongation of their lives, their physio-logical functioning, and their capacities for self-deter-mination—with a recognition that sometimes suchgoods will conflict with each other. But we didn’t needvalue theory to know that these goods are all-purposeneeds. And both objective-list and subjective theoristsagree that such goods promote one’s well-being.Let me close by very briefly sketching what I believe tobe the most promising account of individual well-being(DeGrazia and Millum under review). According to thisaccount, both enjoyment/contentment and the satisfac-tion of narrative-relevant desires (that is, desires whosesatisfaction makes a difference to one’s life-story) areprudentially good for an individual; suffering and thefrustration of narrative-relevant desires are prudentiallybad for an individual. This subjective account featurestwo fundamental sources of well-being: positively experi-enced mental states and a type of desire-satisfaction.Critically, in this view, contact with reality—as contrastedwith illusion or delusion—plays an amplifying role.Enjoyment/contentment is prudentially better when itresponds to an actual state of affairs—as opposed to animagined one. Likewise, the fulfillment of desires is pru-dentially better when those desires are informed andrational. Enjoyment/contentment and narrative-relevantdesire-satisfaction are unified in a single coherentaccount of well-being insofar as both reflect the lived,self-caring perspective of a conscious subject. What thebest objective-list views get right is that the items on theirlists are almost always prudentially valuable for humanbeings. Where they go wrong is in asserting that most ofthe items on the list are ultimate constituents of well-being rather than all-purpose means.DISCLOSURE STATEMENTThe views expressed here are the author’s own. They do notreflect the policy or position of the NIH or any other partof the federal government.72 OPEN PEER COMMENTARIESFUNDINGThis work was supported, in part, by intramural funds fromthe National Institutes of Health Clinical Center.REFERENCESBester, J. 2020. Beneficence, interests, and wellbeing inmedicine: What it means to provide benefit to patients.The American Journal of Bioethics 20(3): 53–62.Brock, D. W. 1993. Quality of life measures in health careand medical ethics. In: The Quality of Life, ed. MarthaNussbaum and Amartya Sen, 95–132. New York: OxfordUniversity Press.Crisp, R. 2017. Well-being. Stanford Encyclopedia ofPhilosophy (plato.stanford.edu/archives/fall2017/entries/well-being/) (accessed December 4, 2019).DeGrazia, D. 1995. Value theory and the best interest stand-ard. Bioethics 9(1): 50–61.DeGrazia, D., and J. Millum. Value theory. In A Theory ofBioethics. (under review).Powers, M., and R. Faden. 2006. Justice and Well-Being. InSocial Justice: The Moral Foundations of Public Health andHealth Policy, 15–49. New York: Oxford University Press.THE AMERICAN JOURNAL OF BIOETHICS2020, VOL. 20, NO. 3, 73–74https://doi.org/10.1080/15265161.2020.1714803OPEN PEER COMMENTARIESVirtues and Phronesis: Making Decisions in the Clinical ContextAisha Y. Malik and Mervyn ConroyUniversity of BirminghamWe are broadly in agreement with Bester (2020).When approaching medical decisions many tensionsneed to be balanced before a decision is made that isin the patient’s best interest, including but notrestricted to their physical wellbeing. Cliniciansencounter uncertainty in making decisions for theirpatients (Jonsen et al. 2010) that is further com-pounded by patient’s (sometimes family’s) values andbeliefs and the circumstances in which decisions haveto be made. Patients are not just bodies with alteredbiochemistry that needs putting right; they are personswith attendant psychological, emotional and relationalfacets (Malik 2011). Each patient is unique in theirlived experiences (Bain 2018). Within this contextdoctors are urged to make ethical decisions- decisionsin their patient’s best interest.Acting in the best interest of the patient and thewider society can be achieved through a duty- based/principlist approach, the approach taken by Bester(2019). We argue for an alternative, albeit comple-mentary, approach to the duty-based beneficence-related decisions. Our approach borrows the conceptof phronesis (practical wisdom) from virtue ethics.Phronesis is considered medicine’s “indispensablevirtue” by Pellegrino and Thomasma (1993).Based on data from a 3-year ethnographic study ofdoctors and GPs (Conroy et al. 2018), we argue for anon-prescriptive approach to help healthcare profes-sionals take account of virtues relevant to the dilemmaunder consideration and make a practically-wise deci-sion that brings about the best outcome for theirpatient, and wider society. The dilemmas raised byBester (2020) show tensions that exists when two the-ories of wellbeing clash: View A is the individual’s(i.e. patients’) own view of the good, derived fromtheir concept of flourishing (in this regard the goal oftheir treatment). In contrast, View B is an objectivelist of things that are important in every person’s life.These are the things that are considered good and isdecided by an objective criterion guided by evidence-based practice. We consider both these as two sides ofthe same coin and a balance between the two can beachieved, through phronesis. By keeping the stakehold-ers central to the decision-making process, phronesisacts as an executive virtue in providing a way forwardto solve the dilemmas encountered in clinical settingand promote the good in morally difficult situations.Bester (2020) proposes a solution that comprisestwo criteria of wellbeing: First, objective functioningi.e. a list of requirements that are necessary toCONTACT Aisha Y. Malik ath3@hotmail.com, a.y.malik@bham.ac.uk Research Fellow, Health Services Management Centre, University ofBirmingham, Birmingham, UK 2020 Taylor & Francis Group, LLCTHE AMERICAN JOURNAL OF BIOETHICS 73

Value Theory, Beneficence, and Medical Decision-Making

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Value Theory, Beneficence, and Medical Decision-Making

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