Ethics and the Metaphysics of Medicine: Reflections on Health and Beneficence.

Ethics and the Metaphysics of Medicine Reflections on Health and Beneficence Written by Kenneth A. Richman Published by MIT Press, Cambridge, MA & London, England, 2004, ISBN: 0262182386, Hardcover, pp. 232, $39.25 CAN

In this book, Kenneth A. Richman discusses the duties of a physician or other health care provider in terms of the so-called Belmont Principles of 'autonomy' and 'beneficence'. He defines autonomy as a state which allows us to achieve, or at least to strive for, our goals or preferences. For a patient to be 'healthy', he says, is to be in such a state; and to be acting autonomously, not just in a random and independent way, but in accordance with an already established pattern of decision making which that patient has previously obeyed.

Richman holds, therefore, that a physician's knowledge of a patient's preferences is central to the provision of responsible health care. The physician's obligation is described as a duty to benefit the patient (beneficence), by helping the patient to achieve his or her preferences. This benefit is seen as applying to the patient as an 'organism,' for example, to improve cardiac or kidney function. It is also understood as applying to the patient as 'a person.' The benefit of the 'organism' is understood merely as a means towards the 'autonomy' of the patient as 'person,' in the choice of treatment. Richman defines a person as a rational being capable of acting in accordance with Kant's Categorical Imperative, which is "Act only according to that maxim by which you can at the same time will that it should become a universal law."

The author ignores Natural Law, which is the capacity of the human being to gain insight, by the use of reason, into the divine law. He also ignores Judeo-Christian revelation. He sees no design or purpose in human existence apart, apparently, from the egocentrically determined satisfaction of preferences of individuals. Indeed, the role he would assign to a health care provider who must carefully assess a patient's goals brings to mind a waiter asking a customer to pick and choose from a menu. The anthropology implicit in this work does not include any meaningful recognition of the spiritual dimension of human existence, or of any spiritual final purpose in human life. The existence of objective moral norms is denied. The bottom line, in ethical terms, is, to be blunt about it, that the physician should do what the patient wants and act in obedience to the patient's choice.

This approach creates many insoluble moral dilemmas. If 'personhood' depends on one's ability to act in accordance with an injunction like Kant's Categorical Imperative, where does that leave those with impaired cognitive function? How does one solve problems created by a conflict of moral duties, e.g. patient autonomy versus just distribution of scarce resources? What does it tell us about how the physician should act if a patient requests abortion, euthanasia, or assisted-suicide?

Knowledge is founded on the real, in the metaphysical. Truth consists in the correspondence of the intellect to its objects, not in the concepts of those objects, which the intellect provides. The author does not seem to have taken this into account. All things have a nature, an order, a design, and therefore a function and a purpose, as any scientist knows. This fact is ignored in this book. Human actions must be consistent with human nature if they are to result in the biological, psychological, moral, and spiritual betterment of the person. This is also ignored. Instead, we are offered a Cartesian formula whereby the concepts and moral choices of an individual patient are mistaken for reality and deemed to justify, and even mandate, compliance on the part of the caregiver.

Professor Richman has limited the study of ethics and medicine to an account of his definitions of autonomy, beneficence, and health and how they might be used in the guidance of medical caregivers in regard to the treatment of patients. By so doing, while ignoring the classical tradition in metaphysics, epistemology, and natural law ethics, and also Judeo-Christian revelation, he has placed himself in an ethical labyrinth from which there is no escape.

JOHN B. SHEA, MD FRCP(C)