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Suffering and the Beneficent Community: Beyond Libertarianism.

These authors have much in common. They are physicians who have heavily invested themselves in philosophical debate; both are critical of a medical ethics that is focused on autonomy, and both see the key to the problem of such an ethos in the concept of suffering; both make bold and sweeping assertions; both are provocative; both are vulnerable.

Loewy's book has the great strength of beginning with an explanation of his own understanding of suffering. To suffer, he argues, one must have the capacity to experience sensation and some awareness of past, present, and future. Suffering is often associated with powerlessness, fear, and alienation from one's community. Without a neocortex and associated limbic system, suffering is impossible.

For Loewy the most basic moral obligation we face is a prohibition: don't cause suffering to any creature who can suffer. He thinks of this obligation as a duty of beneficence, but he believes that we should move beyond this negative duty to try to ameliorate suffering or bring about pleasure: "Entities that have the capacity now or in the future to suffer have a prima facie right not to be made to suffer and share the legitimate expectation that, where possible, all will be done to alleviate suffering."

Loewy notices that not all humans have the same capacity to suffer. The capacity to suffer is related to the capacity to experience, and he suggests that "people with richer lives, richer plans, and a richer capacity for experiencing have a greater stake in their lives than do people whose lives are less complex." That is not to say that the impoverishment of my life is necessarily my fault or even reflective of my basic capacity to suffer: I may be suffering from the impoverishment. But it is to say that people "with an innate capacity to plan their lives, to profit from the lessons of history, or to plot their future intuitively have a different standing from creatures lacking such a capacity." Loewy realizes that it is risky to suggest that some people are more valuable than others, "but the mere mention of the slippery slope must not freeze us into inaction." His general point is that communities must engage in some line drawing about who counts and that the "richness of the biography" may be a relevant factor in the line-drawing discussion.

As a start in that direction he suggests that something is of "primary worth" if it has the capacity to suffer, of "secondary worth" if it is valued by an entity of primary worth. This formulation means that individuals in a persistent vegetative state are of secondary worth--to family members, potential organ recipients, other users of health care resources. Further, "nonhuman animals may well have higher moral standing than do members of the human species."

Community is the main theme of the second half of his book. He argues that communities are held together by a social contract rooted in nurture, beneficence, and the family rather than in fear and mistrust. Thus, relieving suffering is a community obligation. Freedom on these terms is "not an absolute condition of the moral life but rather one of its esteemed values: so beneficence may well be ranked ahead of autonomy as a communal value."

Loewy draws reasonable socialistic (not Marxist) conclusions from his communitarianism. He resists the idea of a natural limit to the human life span because he thinks research will constantly change that limit. He contends that communal decision-making is essential, basic health care needs must be met, and no a priori or dogmatic lines should be drawn.

I hope I have said enough to suggest the general force of Loewy's argument and some of its worrisome points. Animals are deemed beneficiaries but not responsible members of the moral community; the equal worth of all persons--not simply fetuses and individuals in PVS--is questioned; various meanings of freedom and autonomy are not carefully distinguished. Loewy offers provocative uses of organic theories of community and a much richer reading of Kant than some contemporary bioethics. But the potential to justify tyranny and inequality does not perhaps receive adequate attention.

Finally, I should add that bioethics actually plays a very small part in this book, which is essentially an essay in social philosophy by a physician. I would have expected that Loewy's greatest contributions as a philosopher would be more closely related to his medical experience.

The same thing certainly cannot be said about Eric Cassell's book. The brilliant passages in The Nature of Suffering occur in Cassell's discussions of particular patients. Those discussions lead Cassell into generalizations about the nature of persons, the physician-patient relationship, the nature of illness, or the goals of medicine and medical education. To appreciate Cassell fully, one must see him as a prophet to American medicine; like the prophets of old, he appeals to the basic commitment of the profession--which he takes to be the alleviation of suffering--in order to deliver a biting critique of the status quo. As the prophets spoke as Israelites to Israelites, so Cassell clearly speaks as a physician primarily addressing other physicians.

The main theses of his argument can be quickly stated. Modern medicine, he contends, has allowed itself to focus exclusively on disease. But this disease-centered preoccupation breaks down then we realize the impact of environmental or life-style factors on health, and it ignores the fact that a fairly clearly identifiable pathology such as pneumonia may be very different in different people. That is, to help me with my pneumonia a physician needs to know much more about me and my body than the simple fact of my having pneumonia, including many things that may at first seem unrelated to the illness. Classical disease and pathophysiology models are particularly inadequate for understanding chronic illness, "because the illness is generated not only in the body but exists at every level of the human condition, from the molecular to the communal."

Physicians should bear in mind that their main focus should be on suffering persons. People suffer when their "integrity as persons" is threatened, either by overwhelming, uncontrolled, or enduring pain, or by factors relating to the individual's life experience, history, family, social role, and relationships. Personal integrity also includes awareness of the future and one's body, and often a sense of the possibility of transcendence or larger meaning of some sort. Moreover, persons do not know everything about themselves. There are some things about us that others may know better than we do ourselves. At any rate "suffering always involves self-conflict--conflict within the person."

To reduce suffering, we may attempt to live entirely in the present, become indifferent to what is happening, deny the conflict, or replace the threatened part of the self.

Cassell correlates his understanding of the goals of medicine with a distinctive and high view of the physician-patient relationship. (Although virtually all of his discussion uses the terms physician and patient, I think it is important to bear in mind that his claim is more general and bears on the relationships between healers and those in need.) Cassell wants to argue that the relationship has objective power, as shown by the helpful effects that a stranger known to be a physician can have, and that its roots in patient need and dependence mean that analyses in terms of untroubled contractors are irrelevant. The root of the relationship, he thinks, is not so much patient consent as patient trust.

Playing the physician role places one in a position of power and vulnerability. The power requires altruism and self-discipline; the vulnerability is inescapable because good doctoring requires openness to all that is going on with a patient, "but to be open is to be physically and emotionally endangered."

On these terms, the physician's perceptual or diagnostic judgments gain great importance, and Cassell talks about the training of those faculties in sophisticated and helpful ways. He resists the idea that diseases--not symptoms--are real. To understand what's wrong with a patient, the physician must understand the patient's story. Diagnosis should involve the naming of diseases, but that is only a start. "The goal is to find out what is happening in the well as who the patient is; to uncover what... threatens the patient, and why it does so at this time."

Cassell is clear that physicians' judgments must include not only an empirical but also a value component. To understand a patient's particularity one must understand the patient's values. How else could one comprehend suffering or devise ways to help? Physicians should be able to reason about the moral narrative, indeed the aesthetic wholeness, of a life; they must involve themselves with patients. Nontechnical and nonquantifiable information must have its due.

So much for summary. Cassell's book occupies distinctive space on the map of contemporary medical ethics. In contrast with writers who wish to assert patient autonomy in the face of physician abuses of power, Cassell suggests that doctors are more likely to care and risk too little--that their worst vices are an intellectually narrow focus on diseases and self-protection. He does not want to eliminate physician power, but to change its objectives. Thus, on another hand, he can be distinguished from writers whose focus is exclusively on the body. And although this book is an ethical essay by a clinician, it is not "clinical ethics" insofar as that heterogeneous movement avoids generalizations and philosophizing. The book is a natural development of the main themes of Paul Ramsey's The Patient as Person, and it has a clear sibling resemblance to the work of William F. May.

Cassell's great strength lies in his clinical experience, which allows him to analyze inadequate doctoring with great specificity. He realizes that he must try to be concrete about what suffering and persons are, and about what we should expect from physicians. In that sense the book is a gold mine, filled with insight and rich observation.

On the other hand, Cassell's own proposal about the physician's role has the effect of leaving physician power unchecked. I don't mind that, if Cassell is my doctor, but I might mind with other physicians. Cassell says little about other healers whose presence may be therapeutic and whose perspectives may differ from those of even person-centered clinicians (for example, nurses,

clergy, family members). Ironically, one way around this problem might be to root the physician's role even more clearly in the body (as Leon Kass does), thus establishing but also limiting physician expertise.

Cassell is very clear in his reaffirmation of the importance of scientific medicine as one part of the therapeutic bag of tricks. His overall objective is to get doctors to take other dimensions seriously as well. I applaud this goal, but I wish the exhortations to physicians to use power made even clearer that power sharing is a reality to be acknowledged.

A last point, bearing on both books, concerns that tired battleground "autonomy." Sympathetic as I am with Loewy's and Cassell's desire to celebrate interdependence and community, I wish they were a little more subtle in their reading of the opposition. A great deal of what Loewy wants to defend is easily encompassed within the framework of Beauchamp and Childress's Principles of Biomedical Ethics, and Robert Veatch could agree with many of Cassell's practical directives for physicians. Differences exist, and they are more than differences of emphasis, but the theory of biomedical ethics won't really be advanced until contrasting views are assessed in more detail and precision than we get in these two books.
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Author:Smith, David H.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Sep 1, 1992
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