Just Doctoring: Medical Ethics in the Liberal State - Hardcover

Brennan, Troyen A.

Hardcover

ISBN 10: 0520073339 ISBN 13: 9780520073333

Verlag: University of California Press, 1991

Inhaltsangabe

Just Doctoring draws the doctor-patient relationship out of the consulting room and into the middle of the legal and political arenas where it more and more frequently appears. Traditionally, medical ethics has focused on the isolated relationship of physician to patient in a setting that has left the physician virtually untouched by market constraints or government regulation. Arguing that changes in health care institutions and legal attention to patient rights have made conventional approaches obsolete, Troyen Brennan points the way to a new, more aware and engaged medical ethics.

The medical profession is no longer isolated, even theoretically, from the liberal, market-dominated state. Old ideas of physician beneficence and altruism must make way for a justice-based medical ethics, assuming a relationship between equals more compatible with liberal political philosophy. Brennan offers clinical examples of many of today's most challenging medical problems—from informed consent to care rationing and the repercussions of the HIV epidemic—and gives his recommendation for a new ethical perspective. This lively and controversial plea for a rethinking of medical ethics goes right to the heart of medical care at the end of the twentieth century.

Über diesen Titel

Über die Autorin bzw. den Autor

Troyen A. Brennan is Assistant Professor at the Harvard Medical School. He also has a law degree and has taught at the Harvard Law School.

Von der hinteren Coverseite

"A marvelously engaging book, one that . . . [could make] a large difference in how medical-legal issues are understood by physicians and many others in this huge industry."—Theodore R. Marmor, Yale University

"One of the most important and exciting I have read in biomedical ethics in the last few years. The author's firm grounding in medicine and law and his understanding of moral and political philosophy have enabled him to write an exceptionally valuable book that exposes the possibilities and limitations of different models of ethics in a liberal state. . . . I strongly recommend this clear and illuminating book."—James F. Childress, University of Virginia

Aus dem Klappentext

"A marvelously engaging book, one that . . . [could make] a large difference in how medical-legal issues are understood by physicians and many others in this huge industry."Theodore R. Marmor, Yale University

"One of the most important and exciting I have read in biomedical ethics in the last few years. The author's firm grounding in medicine and law and his understanding of moral and political philosophy have enabled him to write an exceptionally valuable book that exposes the possibilities and limitations of different models of ethics in a liberal state. . . . I strongly recommend this clear and illuminating book."James F. Childress, University of Virginia

Auszug. © Genehmigter Nachdruck. Alle Rechte vorbehalten.

Just Doctoring: Medical Ethics in the Liberal State

By Troyen Brennan

University of California Press

Copyright © 1991 Troyen Brennan
All right reserved.
ISBN: 0520073339


1
The Liberal State

Newspapers and television often feature controversial subjects arising out of health care. More and more these stories seem to underscore conflicts between institutions and bureaucracies as much as they do the human struggles that were the central focus of such fare ten or fifteen years ago. For instance, a man in Chicago "pulls the plug" on the ventilator that keeps his comatose infant alive. He faces criminal charges. One can barely imagine the emotions and suffering associated with such an act. But the father's decision has come after a hospital lawyer refused to help the family seek a court order to remove the child from the ventilator. The lawyer reasons that since the hospital was not receiving any reimbursement for this child's care, a court might suspect that the hospital's removal of life support was prompted by financial motives.1

Consider these other stories: The lover of a movie star who has died of the acquired immunodeficiency syndrome (AIDS) sues the estate and the movie star's physicians because he was never warned that the star was seropositive for the human immunodeficiency virus (HIV). The physicians involved in this case contend that they thought they owed their patient confidentiality. The lover is awarded $5 million. He has not contracted the virus, so observers surmise that the court is sending physicians a message that they must warn individuals who might contract the HIV from one of their patients.

The government agency that determines how physicians should be reimbursed under Medicare, the Physician Payment Review Committee (PPRC), considers capping expenditures. They reason that physicians will then be forced to learn how to ration care, and thus save

money for the government. But the American Medical Association (AMA) asserts that this initiative will cause incalculable harm to the elderly.

Each of these examples involves institutions and professions that most physicians are suspicious of, if not contemptuous: the government, the courts, the legal profession, and health care administrators. Yet each of these examples also touches on issues that most doctors would feel are imbued with ethical considerations. This is the dilemma of medical ethics in the 1990s. Most ethical issues that physicians now face are intertwined with legal and political issues.

Most physicians believe they are equipped to deal with ethical problems that arise in the practice of medicine. They would prefer to handle such problems simply by consulting their own sense of morality and doing the reasonable thing. Physicians have tended to isolate themselves from the economic, political, and legal aspects of difficult moral issues that occur when caring for patients. Traditionally, the patient-doctor contract has excluded all extraneous concerns, and thus the focus in medical ethics has been on interpersonal morality.

Today, however, institutions assert themselves in most "ethical problems" facing physicians, inevitably leading to questions on the relation of law to ethics and morality. Notions of justice contend with those of doctor-patient trust. Political philosophers expect conflicts to arise between individuals struggling with ethical concerns and the laws of the state. As Thomas Nagel notes, the impartiality of liberalism, the guiding political philosophy of Canada, Great Britain, and the United States, provides a context for and orders the ethical decision making of the individual citizen.2 The physician should thus be familiar with the legal and political context of ethical decision making.

What should the physician do when confronted with legal and political issues arising from the practice of medicine? One answer is that she should learn about issues of justice and political fairness. An initial education might involve defining the central terms of such issues. What do the words law, morality, ethics, justice, and liberalism really mean? Webster's has those answers.3 Morality, on the one hand, is defined as "a doctrine or system of moral conduct." The adjective moral is defined as "of or relating to principles of right or wrong" and is synonymous with ethical. Just, on the other hand, is an adjective that means "acting or being in conformity with what is morally good or upright." Justice is the "maintenance or administration of what is just" and is also the "quality of conforming to the law."

Clearly there is a great deal of overlap in the meaning of these terms, yet they present many different nuances. All deal with correctness of action, and with the qualities of right and wrong. All feature a sense of principled action and of rational relationships. But concepts of morality and ethics do seem less systematic—if you like, less specific—than do concepts of law. Conforming with law is different from conforming with an ethical principle. Justice is institutionalized in a way that morality is not.

What about liberalism? Webster's relates that liberalism is "a political philosophy based in belief in progress, the essential goodness of man, and the autonomy of the individual and standing for the protection of political and civil liberties." That sounds like it has a lot to do with law, justice, and morality; it also sounds like a decent description of the political philosophy that guides the United States, Canada, and Great Britain, to name a few of what I refer to as liberal states. Given the relationship of medical ethics to moral-political concerns in our liberal state, a firm grasp of liberalism must be central to the enterprise of this book. If we can understand what the liberal state is all about, it will be much easier to understand why issues of law and justice are and should be an increasingly important part of medical ethics.

The Core of Liberalism: Negative Freedom

What, then, are the core values of liberalism? Although there is no easy answer, one can probably safely say that liberals believe individuals should be able to make choices, and that the state should be impartial to these choices. Thus liberalism requires an area of noninterference for the individual, or freedom from interference. Isaiah Berlin has called this the sphere of negative freedom and his discussion can help elucidate the essence of the liberal state.4 Berlin notes that there are two senses of freedom in political discussion. They are as follows:

The first of these political senses of freedom ... which I shall call the negative sense, is involved in the question, "What is the area within which the subject—a person or group of persons—is or should be left to do or be what

he wants to do or be without interference by other persons?" The second, which I shall call the positive sense, is involved with the answer to the question, "What or who is the source of control of interference, that can determine someone to do or be, one thing rather than another?"5

Berlin thus constructs two opposing senses of the word freedom. One centers on the individual's sphere of action. This sphere is to be quite large and the individual is to be left, to a large extent, unbridled. The other type of freedom, the positive type, is totally different. It involves the use of power or coercion by some in society, or the state itself, to help perfect...

Details zur Ausgabe

• Verlag: University of California Press
• Erscheinungsdatum: 1991
• Sprache: Englisch
• ISBN 10: 0520073339
• ISBN 13: 9780520073333
• Einband: Gebundene Ausgabe
• Anzahl der Seiten: 287
• Kontakt zum Hersteller: Nicht verfügbar
• Verantwortliche Person: Nicht verfügbar