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For the Patient's Good: The Restoration of Beneficence in Health Care.

For the Patient's Good: The Restoration of Beneficence in Health Care.

For the Patient's Good is a superb and much needed book. Until now a disciplined approach to (and an argument for) the inclusion of beneficence as a moral imperative has been lacking in medical ethics, even though Engelhardt in his brilliant book The Foundations of Bioethics includes beneficence as the necessary (but not morally binding) content of medical ethics. This point of view, unfortunately, leaves us in a hole: If benevolence is volitional and not a moral imperative, it assumes a nonbinding and, therefore, ethically supererogatory role. Beneficence, moreover, assumes an almost aesthetic quality; it is "nice" like the "niceness" of a Mozart symphony or, perhaps, of raspberry sherbet. Inevitably one is left with an ethic of stark individualism devoid of any sense of community. Such an ethic, when it comes to dealing with our fellow-creatures (let alone our fellow-creatures in a medical setting) leaves one unfulfilled.

As Pellegrino and Thomasma clearly recognize, beneficence is more than merely a desirable requirement of medical practice. They ground beneficence not only in the historical facts of medical obligation but also, and perhaps more important, in the broader requirements of general ethics which, if it is to function in civilized society, must transcend an ethic of mutual nonharm.

The authors most carefully steer between the Scylla of autonomy and the Charybdis of paternalism. This is, most certainly, not an easy course to steer. An extreme respect for autonomy easily leads to a callous disregard of the welfare of the very individual that this respect is supposed to protect. But an overly high value attached to beneficence can lead to flagrant examples of paternalism in which the very idea of acting beneficently (let alone benevolently) is destroyed.

The authors seek a middle road between autonomy and paternalism by developing the notion of "beneficence in trust." "Beneficence in trust" implies that while beneficence must be the dominant guiding principle of medical care it must, if it is to function for patients' self-selected "good," encompass a proper concern for patients' values and ultimately for patient autonomy. Further, this principle is a two-way street: patients as well as physicians have their part to play in this relationship. (A very worthwhile chapter is devoted to the "Good Patient.") Negotiations that occur in the course of treatment must be guided by mutual trust, understanding and beneficence. Under the impact of illness, this is a burden mainly (but not solely) carried by health professionals.

In delineating guidelines that would allow one to address specific problems, the authors are careful to refrain from giving explicit rules. A charge of vagueness, however, is given the lie by a very careful working out of hierarchies of values and goods. The authors develop the notion of a four-fold and hierarchical meaning of the "patient's good." It is, as they point out, a peculiar "good" in that it applies to persons in particular existential circumstances: patients are in need of help and often in a state of at least temporarily altered autonomy.

This fourfold good consists first in the ultimate good that for the patient encompasses the aim and meaning of life. It is "the good to which we return whenever we are forced to make choices between competing goods." For the religious person it may be his/her perception of God; for others it may be a similar principle or, in some instances, hedonism or pure self-service. Whatever it is, the patient's ultimate good must take precedence over other goods. The second type of "good" refers to the "good of the patient as a human person": that good which eventuates in the freedom to make reasoned choices. It is the good of autonomy, enjoined on us out of a Kantian respect for persons. It differs from the preceding in dealing with specific choices rather than with an ordering principle that guides such choices.

The third component is the patient's particular good, that is the "good" which in a given situation is perceived by the patient as serving his/her specific ends. Such a good emerges from the notion of autonomous choice and conforms to a consistent vision of the ultimate good. It is the sort of notion that impels a patient to choose one over another form of treatment. And finally, the last "good" encompasses the biomedical good that, in the absence of interfering values, will guide the course of therapy. It is the basis of the coming together in the patient-physician relationship and constitutes the raison d'etre of that relationship. However, neither physician nor patient are necessarily or entirely bound by it: The biomedical good may interfere with higher goods and then may have either to be compromised or, ultimately, to yield. Throughout the book this vision of a "fourfold good," is applied in many situations and examples.

The book is well written, forceful, direct, and a joy to read. It should be of use to anyone working in the field as well as to thoughtful physicians who must think about and deal with concrete problems. Those who look for specific answers to troubling questions that can then be simply applied in concrete situations will be disappointed: This book is not meant to be a substitute for the exercise of moral agency nor is it willing to wash its hands of troubling questions by invoking one absolute principle. And those who see the world as constituted by individuals (or by individual nations) tenuously bound merely by a promise of nonharm one to another, will be unhappy with this book: they will see in it a dangerous dilution of absolute autonomy. Those, however, who realize that communities large and small are united and served by mutual trust and caring and who realize that such trust and caring does indeed entail a decent regard for personal autonomy, will be delighted and gratified, Pellegrino and Thomasma are, I feel, to be congratulated for having produced one of the fundamental books in the field.
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Author:Loewy, Erich H.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Jan 1, 1989
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