For The Patient's Own Good ---
The Restoration of Beneficence in Health Care
Edmund D. Pellegrino, MD and David C. Thomasma, PhD
(240 pp., $41.50, ISBN: 0-19-504319, Oxford University Press, New York, NY, 1988.)
Dr Pellegrino, professor of Medicine and Medical Humanities at Georgetown, is joined by Dr Thomasma, Professor of Medical Ethics at Loyola in Chicago, in reviewing the post-Hippocratic era, which has shaken and even dismantled portions of the ethics of Hippocrates. Pellegrino feels there have been more changes in medical ethics in the last two decades than in its twenty-five-hundred-year history. There is serious question about whether the medical profession can ever again be united under a common set of moral commitments.
He details the two major ethical theories currently vying for dominance in medical ethics. The first stresses the liberty and autonomy of the individual. It gathered strength in the nineteenth century in response to the depreciation of personal worth that accompanied the Industrial Revolution. This theory is grounded in ethics as rights, duties, and obligations. The second theory stresses social utility: social good, rules of conduct, and social accountability.
Applied to the physician-patient relationship, the first theory imposes on the physician the obligation of respect for the patient's self-determination. The second theory requires that the physician act to maximize benefits and goods even if this might demand acting without the patient's consent. It sanctions overriding the patient's autonomous decision, if that decision is not judged by the physician to be in the patient's or society's good.
Pellegrino gives us hope for reconstruction by recounting the forces of deconstruction that have been at work in Western society at least since the Enlightenment. He feels the chief cause is the loss of moral consensus and the moral authority of religious institutions. The resulting moral diversity, he feels, has caused an undeniable moral defection of some physicians. As a result, patients and physicians cannot assume they will share any common set of moral values. They may find that at the moment when the most fateful decisions must be made, that they are moral adversaries. A legalistic rather than a fiduciary climate then comes to dominate many physician-patient relationships. Litigation and the court decisions become the arena for the settlement of ethical disputes.
Every one of the prescriptions and proscriptions of the Oath of Hippocrates has been questioned or openly violated: Abortion is no longer forbidden; confidentiality has been challenged as outmoded; direct euthanasia is proposed and even quietly practiced; sexual relationships with patients are deemed therapeutic by some psychiatrists. The benignly paternalistic image of the physician so characteristic of the ethos of Hippocrates is everywhere under attack. The author states that even traditional medical ethics itself is perceived by some to be simply a mechanism for preserving professional power and privilege.
Pellegrino proposes a third theory based on beneficence, that is, on acting for the good of the patient and on virtue, which he feels is more appropriate to the special context of the medical encounter today. This theory was originally formulated by Socrates, Plato, and Aristotle, reinforced by the Roman Stoics, and modified by Saint Thomas Aquinas. It was the theory that prevailed in Western culture until the Enlightenment, when it came under attack by the French philosophers and the British empiricists.
Pellegrino's chapter on gatekeeping was of especial interest since I had previously written an editorial on the subject. Since 75 percent of the nation's expenditures for health care is our responsibility, we are the traditional or de facto gatekeepers. This is our responsibility to practice rational medicine --- use only those diagnostic and therapeutic modalities that are beneficial and effective for the patient. A second form or negative gatekeeping is usually found with some form of prepayment system in which the physician tries to limit the use of health care services which conflicts with the physician's role as primary advocate and as society's guardian of resources. The third form or positive gatekeeping is a physician encouragement in the use of health care facilities and services for personal or corporate profit. The latter two are morally indefensible.
Beneficence includes more than the negative principle primum non nocere, but entails positive enhancement of all components packed into the complex notion of the patient's good. Pellegrino argues that medicine is neither a science nor an art, but a practice that gives rise to ethical axioms. If these axioms are violated, the good of medicine is also violated.
There is much more. This volume needs to be on our consul-tation desk
and given space and attention to balance the deluge of morally unjustifiable
information coming from a large number of groups and organizations who don't
have our patient's interest at heart.
Reviewed by Delbert H. Meyer, MD
Dr Meyer is a pulmonologist practicing in Sacramento and is on the editorial boards of Medical Sentinel and Sacramento Medicine. He can be reached by e-mail: email@example.com.
Originally published in the Medical Sentinel 1999;4(3):114 Copyright ©1999 Association of American Physicians and Surgeons (AAPS).